Transcarotid Versus Surgical Aortic Valve Replacement for the Treatment of Severe Aortic Stenosis

BACKGROUND: Current guidelines recommend surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and unfavorable iliofemoral access. Transcarotid transcatheter aortic valve replacement (TC-TAVR) has emerged as an alternative access in suboptimal transfemoral candidates, but no data exist comparing TC-TAVR and SAVR. The main objective of this study was to compare the clinical outcomes in a propensity-matched population of TC-TAVR and SAVR patients with severe aortic stenosis. METHODS: A total of 786 patients (SAVR, 352; TC-TAVR, 434) were included, and a total of 182 patients were propensity-matched and included in each group. The primary outcome was a composite of death from any cause, stroke/transient ischemic attack, and procedure-related or valve-related hospitalization at 30 days and at 1 year. Data were prospectively collected in dedicated databases, and clinical events were defined according to Valve Academic Research Consortium-3 criteria. RESULTS: Baseline characteristics were well balanced between the matched groups, and the mean age and Society for Thoracic Surgeons score of the study population were 75 years and 3.6%, respectively. At 30 days, the SAVR group showed a higher rate of the primary composite outcome compared with the TC-TAVR group (12.6% versus 4.3%; hazard ratio, 2.93 [95% CI, 1.45-5.94]). Acute kidney injury stages 2 to 4, bleeding events, and new-onset atrial fibrillation occurred more often in the SAVR group during the hospital period (P<0.001). In contrast, vascular complications and the need for permanent pacemaker implantation occurred more often in the TC-TAVR group (P=0.01 and P=0.001, respectively). At 1-year follow-up, there were no significant differences between groups in the primary outcome rates (SAVR, 19.7% versus TC-TAVR, 12.7%; hazard ratio, 1.63 [95% CI, 0.98-2.73]). CONCLUSIONS: TC-TAVR was associated with improved 30-day clinical outcomes compared with SAVR, with no significant differences in death, stroke, and hospitalization at 1-year follow-up. These findings suggest that TC-TAVR may be a valid alternative to SAVR in nontransfemoral-TAVR candidates.