Background: We sought to evaluate the outcomes of transapical and transaortic transcatheter aortic valve replacement (TAVR) in high-risk patients who were not eligible for the transfemoral access and had a logistic EuroSCORE-I ≥25% and a Society of Thoracic Surgeons (STS) score greater than 6%. Additionally, the “STS/ACC TAVR In-Hospital Mortality Risk App” was analyzed.

Methods: Between January 2016 and May 2020, 126 patients at very high surgical risk underwent transapical (n=121) or transaortic (n=5) transcatheter aortic valve replacement. All procedures were performed in a hybrid operating theater using the SAPIEN 3™ or the ACURATE TA™ prosthesis. Data collection was prospectively according to VARC-2 criteria.

Results: All patients presented with high risk-scores (logistic EuroSCORE-I 40.6±14.0% (mean±SD), STS-score 7.9±4.6%, and STS/ACC-score 8.4±3.4%). In all patients the technical success of the aortic valve implantation has been achieved. Operative, in-hospital and 30-days mortality, were 0%, 7.9% and 13.5%, respectively. Survival was 72% at 1 year and 48% at 4 years. Expected/observed in-hospital mortality was 1.0 for the STS-score and 1.06 for the STS/ACC-score. Kidney failure, low ejection fraction, and postoperative acute kidney injury, hemorrhage, and vascular complications were identified as independent predictors for 30-day mortality in the regression analysis. 

Conclusions: Transapical and transaortic transcatheter aortic valve replacement in high-risk patients unsuitable for the transfemoral access remains a reasonable treatment option in a high-risk cohort. The STS and STS/ACC-score are highly accurate in predicting in-hospital mortality in high-risk patients undergoing TAVR.