Transfemoral versus transapical approach for transcatheter aortic valve implantation: a systematic review and meta-analysis of adjusted studies
Authors: Hage F , Harris A R , Clerc O , Altibi A , Hage A , Hamaya R , Papatheodorou S 
Published: October 2021

Abstract

Background
In selected patients with severe aortic stenosis, transcatheter aortic valve implantation (TAVI), via either transfemoral (TF) or transapical (TA) access, offers a less invasive alternative to standard surgical replacement. Comparison of TF- vs. TA-TAVI is usually confounded by the higher comorbidities of patients undergoing TA-TAVI, rendering the observed comparison of the TF- vs. TA-approach unclear. The present meta-analysis provides updated evidence of this comparison by focusing on studies reporting adjusted outcomes.

Methods
A systematic review of the literature was performed in MEDLINE, EMBASE, Web of Science, clinicaltrials.gov, and Cochrane database. We only included studies in which the comparison between TF- and TA-TAVI was adjusted for potential confounders. Primary outcomes were early and mid-term mortality. Secondary outcomes included cardiovascular events, bleeding, pacemaker, and acute kidney injury. Survival data was either obtained directly from reported outcomes or estimated from Kaplan-Meier curves. Meta-regression was used to adjust for follow-up duration. Meta-analyses were performed using random effects models on odds ratios (OR) and hazard ratios (HR). The protocol was registered on PROSPERO (ID: CRD42020218163).

Results
A total of 24 studies with 36,158 patients were included in the present analyses. Of these studies, 7 used propensity score adjustment techniques and 17 used multivariable regression. TA-TAVI was associated with significantly higher postoperative mortality at 30 days (OR=1.67; 95% CI, 1.34 to 2.09; p&lt;0.001) and 1 year (HR, 1.36; 95% CI, 1.21 to 1.53; p&lt;0.001). However, meta-analysis of studies censoring patients who died in the first 30 days showed no significant difference in 1 year mortality by access route (HR, 1.20; 95% CI, 0.95 to 1.52; p=0.13). TA-approach was associated with increased perioperative surgical complications, such as bleeding (OR, 1.46, 95% CI, 1.09 to 1.96; p=0.012), acute kidney injury (OR, 2.31, 95% CI 1.60 to 3.33; p=0.001), and myocardial infarction (OR, 1.83, 95% CI 1.06 to 3.16; p=0.029). TA-TAVI was associated with reduced vascular complications (OR, 0.32, 95% CI 0.18–0.56; p&lt;0.001), late postoperative aortic regurgitation (OR, 0.48, 95% CI 0.30 to 0.75; p=0.001), and a trend towards less pacemaker requirement (OR, 0.80, 95% CI 0.60–1.08, p=0.15).

Conclusions
Based on this meta-analysis of adjusted studies, a TA approach is associated with higher early and mid-term mortality compared to TF-TAVI. Excess mortality is likely driven by higher perioperative bleeding, renal complications and myocardial infarction. TA-TAVI did confer some benefits, such as reduced vascular complications, late postoperative aortic regurgitation, and a trend towards less pacemaker requirement. The optimal TAVI route should be based on individualized assessment by a multidisciplinary team. Longer follow-up and randomized studies are needed to ascertain long-term outcomes.

Funding Acknowledgement
Type of funding sources: None. Figure 1Figure 2