Mid-term Outcome of TA-TAVI for Aortic Stenosis and Porcelain Aorta and a Systematic Review: TF or TA-TAVI for Aortic Stenosis and Porcelain Aorta?

Aim: The data relating to the outcome of the patients undergoing transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) and porcelain aorta (PAo) are very scarce. We aimed to analyze, early and mid-term outcome of the patients undergoing transapical-TAVI (TA-TAVI) at our institution. Additionally, we postulated that the TA approach may be associated with favorable neurological outcome, so we conduct a systematic literature review comparing the transfemoral (TF) and TA approach in patients with PAo.

Methods: 15 inoperable patients (ES II 10.68%, STS 6.39%, age 73, male 86%) from 2011 to 2017 underwent TA-TAVI for sever AS and PAo at our institution. The assessment of PAo was done either intraoperatively after aborted sternotomy or via CT for elective TAVI. According to VARC-2 definitions, device success, early safety, clinical efficacy and time related valve safety were evaluated. Furthermore, a systematic review of the main registries and studies was performed and the TF and TA-TAVI approaches in terms of mortality and neurological outcome were compared.

Results: Peripheral vascular (73.3%) and coronary artery disease (86.6%) were very frequent, 60% were Redos and 20% with experienced stroke. Median follow up time was 16 months. In all patients, TA-TAVI was performed with a rate of success 100%: p _mean 8 ± 4 mm Hg with no PVL ≥ 2. 30-days mortality was 6.6%. No disabling stroke was registered. No coronary ischemia was observed. 6 months/1 year/2 year survival rate was 93%/ 82%/ 50% respectively. In the main registries and studies the PAo occurs in the TAVI population with a high incidence (10.7% in German TAVI Registry, 19% in PARTNER B cohort). Although the high incidence of PAo, only The German and Canadian TAVI registries are reporting of outcomes in patients with PAo. In Canadian registry (PAo incidence 18%), stroke 3.0% in TF vs 1.7% in TA. The German Registry results: mortality, stroke and coronary ischemia rates significant higher in patients with PAo (81.6% TF approach). A five-center study (Castrodeza et al) results: 30 days mortality: 13.63% in TF vs 0% in TA. Stroke: 22.72% in TF vs 0% in TA.

Conclusion: TA-TAVI can be performed with very high success in patients with PAo. Very good early and mid-term outcomes can be achieved. The TF approach in patients with PAo is likely to be associated with high mortality and stroke rates.