Outcome of transcarotid versus transthoracic access for transcatheter aortic valve replacement

For millions of people, the heart's main valve becomes a narrow, stiff gate that refuses to open properly, a condition known as aortic stenosis. This blockage forces the heart to work harder to push blood through, eventually leading to fatigue, fainting, and heart failure. For decades, the only way to fix this was to open the chest with a large knife, stop the heart, and sew in a new valve. While effective, this major surgery carries significant risks, especially for older or frailer patients. In recent years, a less invasive method called transcatheter aortic valve replacement has become the standard of care. Instead of opening the chest, doctors thread a new valve through a blood vessel in the groin, guiding it up to the heart and expanding it into place. However, for a small group of patients, the vessels in the groin are too twisted, too narrow, or too damaged to allow this path. These patients still need a new valve, but doctors must find a different route to get there.

When the groin path is blocked, physicians have historically turned to two other options: cutting into the chest wall to reach the heart directly, or accessing the heart through the carotid artery in the neck. The chest approach, which involves opening the rib cage, is quite invasive and often leads to a longer, more painful recovery. The neck approach is newer and avoids the chest entirely, but because it is a more recent technique, doctors did not have enough long-term data to know if it was truly safer or better for the patient's future. A team of researchers at Albany Medical Center set out to compare these two alternative routes. They looked at patients who could not use the standard groin path and examined how they fared after the procedure, focusing on immediate recovery, complications, and survival over several years.

The researchers reviewed the medical records of 155 patients who underwent the valve replacement between 2016 and 2024. To make a fair comparison, they matched patients from the neck group with those from the chest group who had similar ages, medical histories, and heart conditions. This careful matching ensured that any differences in outcomes were likely due to the access route itself rather than the underlying health of the patients. The study found that patients who received the valve through the neck artery had a much smoother immediate recovery. None of the patients in the neck group developed new-onset atrial fibrillation, a common irregular heartbeat that often occurs after heart procedures, whereas more than ten percent of the chest group did. Additionally, patients who went through the neck stayed in the hospital for an average of 4.9 days, while those who went through the chest stayed for an average of 7.7 days.

While the neck route offered a quicker and less complicated start, the long-term picture was more balanced. Over the course of the study, which followed patients for an average of more than two years, the survival rates for both groups were similar. The researchers calculated that after five years, about 70 percent of the neck group was still alive, compared to about 54 percent of the chest group. Although the neck group appeared to have a higher survival rate, the difference was not statistically significant, meaning it could have happened by chance given the number of patients involved. The study also noted that patients in the neck group were readmitted to the hospital for heart-related issues more often than those in the chest group during the later years of follow-up. The authors suggest this might be because more patients in the neck group survived long enough to be readmitted, rather than the neck route causing more problems.

The findings reinforce a growing trend in heart care that favors less invasive methods whenever possible. The study confirms that accessing the heart through the carotid artery in the neck results in fewer immediate complications, such as irregular heartbeats, and allows patients to leave the hospital sooner than those who require a chest incision. While the long-term survival rates for both methods appear comparable, the reduced trauma of the neck approach offers a clear advantage in the critical period right after the surgery. This evidence supports the idea that when the standard path through the groin is unavailable, the neck is a preferable alternative to opening the chest, offering a gentler path to a new heart valve without sacrificing long-term survival.