Dose approach matter?A Meta-analysis of outcomes following transfemoral versus transapical transcatheter aortic valve replacement

Background: Transcatheter aortic valve replacement (TAVR) has gained increasing acceptance for patients with aortic disease. Both transfemoral (TF-TAVR) and transapical (TA-TAVR) approach were widely adopted while their performances are limited to a few studies with controversial results. This meta-analysis aimed to compare the mortality and morbidity of complications between TF- versus TA-TAVR based on the latest data. Methods: Electronic databases were searched from January 2005 to December 2019. RCTs and observational studies comparing the outcomes between TF-TAVR versus TA-TAVR patients were included. Heterogeneity assumption was assessed by an I2 test. The pooled odds ratios(OR) or mean differences with corresponding 95% confidence intervals (CI) were used to evaluate the difference for each end point using a fixed-effect model or random-effect model based on I2 test. Results: The meta-analysis included 1 RCT and 18 observational studies, enrolling 12,953 patients (TF-TAVR, n=8,649 and TA-TAVR, n=4,304). Compared with TA-TAVR, TF-TAVR patients showed significantly lower rate of postoperative in-hospital death (OR=0.63, 95%CI 0.54-0.74, P<0.001) and 1-year death(OR=0.53, 95%CI 0.41-0.69, P<0.001). Incidence of major bleeding and acute kidney injury were lower, whereas those of permanent pacemaker and major vascular complication were higher in TF-TAVR patients. There were no significant differences between TF-TAVR versus TA-TAVR for stroke and mid-term mortality.Conclusions: There were fewer early deaths in patients with transfemoral approach, whereas the number of mid-term deaths and stroke was not significantly different between two approaches. TF-TAVR was associated with lower risk of bleeding, acute kidney injury as well as shorter in-hospital stay, but higher incidence of vascular complication and permanent pacemaker implantation.