Author + information
- Augusto D’Onofrio, MD∗ (, )
- Andrea Colli, MD and
- Gino Gerosa, MD
- ↵∗Division of Cardiac Surgery, University of Padova, Centro Gallucci, Via Giustiniani 2, Padova 35128, Italy
We read with interest the paper by Greenbaum et al. (1), which describes an alternative access for transcatheter aortic valve replacement (TAVR) in patients who, according to the authors, were not eligible for any of the “conventional” accesses: transfemoral (TF), transapical (TA), transaortic (TAo), and trans-subclavian.
We would like to discuss some aspects of this paper that we think are questionable.
The authors enrolled, in one single center, 19 patients in 6 months, with no “conventional” available access. In our center, we have performed more than 400 TAVRs in 6 years, by use of all accesses, and we have never denied TAVR to a patient because they were deemed ineligible for all “conventional” approaches. It seems that for this study, the caval-aortic access was selected as the primary option in patients who had some risk factors but who were not really ineligible for any of the “conventional” approaches. The authors state that these patients were suitable neither for TA nor for TF. Although the contraindications for TF-TAVR are well defined by vessel diameter and size of available sheaths, there is only one absolute contraindication for TA-TAVR: the presence of an apical aneurysm with mural thrombi. All the other mentioned conditions such as low ejection fraction, chronic obstructive pulmonary disease, chest irradiation, previous cardiac surgery, and obesity only generate a slight increase of the risk of the TA approach and should not be considered as absolute contraindications. All these conditions, which, for the authors, contraindicated TA- and TAo-TAVR, have not been identified as independent risk factors for mortality. The incidence of access-related complications in TA-TAVR is as low as 1%, and the great majority of such complications are successfully managed through the same thoracotomy without the need for conversion to open surgery (2).
According to the authors, for the first 11 patients, TAo-TAVR was not an option. This should be better explained. The only contraindication for TAo-TAVR is porcelain aorta. All the others are simply risk factors. Furthermore, even if TAo-TAVR was an off-label procedure at the time of this study, it was already a well-established minimally invasive technique with hundreds of cases reported in the literature (3). On the other hand, caval-aortic access had no proof in humans, and consequently an important ethical issue may arise.
Have the authors tested whether the presence of aorto-caval fistula affects the management of flow during cardiopulmonary bypass, especially in cases of emergency? What is the cannulation strategy in these patients? Have the authors tried to insert a venous cannula in a vena cava in which the TAVR sheath is already in place? With experience, we have learned that the creation of a reliable safety net in the context of a multidisciplinary team approach (4) is crucial to effectively manage TAVR-related complications. What is the safety net in these patients?
In Figure 3B of their paper (1), the authors show a caval-aortic access at the level of an abdominal aortic aneurysm: we believe that this carries higher risks than a TA access in a patient with chronic obstructive pulmonary disease or than a TAo approach in an obese patient.
We believe that the development of this technique has been made with the purpose to perform at any cost a percutaneous TAVR procedure in patients who do not meet the criteria for a simple TF-TAVR. Minimally invasive surgical approaches for TA- and TAo-TAVR have shown excellent results and have few real absolute contraindications; therefore, they should be considered as the first choice when a TF approach is not feasible. It is almost impossible to find a patient who is truly not suitable for any of the currently available TAVR approaches that have proven to be safe, effective, and reliable thus far.
Please note: Drs. D’Onofrio and Gerosa are physician proctors for Edwards Lifesciences TAVR program. Dr. Colli has reported that she has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Greenbaum A.B.,
- O'Neill W.W.,
- Paone G.,
- et al.
- Hayashida K.,
- Romano M.,
- Lefèvre T.,
- et al.
- Seiffert M.,
- Conradi L.,
- Baldus S.,
- et al.