Safety Of Transcatheter Aortic Valve Replacement(TAVR)Through Different Approaches: A Meta-analysis

Objective: To evaluate the early and mid-term safety of transcatheter aortic valve replacement through three different approaches via transfemoral,transapical and transsubclavian by meta-analysis.Methods: We systematically searched the clinical comparative trials published before June 2019 from databases including Pub Med,Web of Science,Embase and Cochrane Library,evaluating the safety of transcatheter aortic valve replacement through transfemoral,transapical or transsubclavian approaches.The information of all-cause mortality at 30 days,1 year,2 years and the incidence of common complications at 30 days after operation(including pacemaker-dependent block,major vascular complications,severe bleeding events,acute renal injury and stroke)were exacted,and a meta-analysis was conducted by Review Manger 5.3 software.Results: This study included 11 literatures,with a total number of 7833 cases,containing 5348 patients by TF TAVR,1796 patients by TAp TAVR and 689 patients by TSc TAVR.The results of the meta-analysis are as follows:(1)At 30 days after operation,the mortality of TF and TSc approaches were lower than the TAp approach(TF vs TAp: OR=0.57,95% CI: 0.39-0.84,P=0.004;TSc vs TAp: OR=4.12,95% CI:1.93-8.79,P=0.0003).There was no significant difference between the TF and TSc approaches(TF vs TSc: OR=0.98,95% CI: 0.38-2.51,P=0.97);at 1 year,there was no significant difference in mortality among the three approaches(P>0.05);at 2 years,there was no significant difference between TSc and TF or TAp approaches(TF vs TSc: OR=1.21,95% CI: 0.95-1.54,P=0.13;TSc vs TAp: OR=1.02,95% CI:0.76-1.36,P=0.91).(2)The incidence of acute kidney injury after TF approach was lower than TAp approach(OR=0.30,95% CI: 0.22-0.41,P<0.00001).(3)There was no significant difference in major vascular complications between TSc and TF or TAp approaches(TF vs TSc: OR=0.75,95%CI: 0.38-1.49,P=0.41;TSc vs TAp: OR=1.37,95%CI: 0.56-3.32,P=0.49).(4)There was no significant difference in severe bleeding events between TF and TSc(OR=0.97,95%CI: 0.53-1.76,P=0.92).(5)There was no significant difference in the incidence of postoperative stroke,pacemaker dependent block among the three approaches(P>0.05).Conclusion: Compared with TF and TSc,TAp approach has a higher incidence of early mortality and acute renal injury after operation.Although the valve delivery system of TAVR has been optimized in recent years,the incidence of vascular complication in TF approach is still high.The mortality and complications of TSc were similar to TF approach.In summary,TSc approach is not only an alternative to TF approach,but also the first choice in some patients with poor condition of iliofemoral artery.