Abstract
BackgroundThe transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; however, few studies have compared their outcomes.MethodsWe performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. The study was prospectively registered with PROSPERO (registration number: CRD42017069788). We searched Medline, PubMed, Embase, and Cochrane databases for studies reporting the outcomes of DAo or TAx TAVR in at least 10 patients. Studies that did not use the Valve Academic Research Consortium definitions were excluded. We included studies that did not directly compare the two approaches and then pooled rates of events from the included studies for comparison.ResultsIn total, 31 studies were included in the quantitative meta-analysis, with 2,883 and 2,172 patients in the DAo and TAx TAVR groups, respectively. Compared with TAx TAVR, DAo TAVR had a lower Society of Thoracic Surgery (STS) score, shorter fluoroscopic time, and less contrast volume use. The 30-day mortality rates were significantly higher in the DAo TAVR group (9.6%, 95% confidence interval (CI) = [8.4–10.9]) than in the TAx TAVR group (5.7%, 95% CI = [4.8–6.8]; P for heterogeneity <0.001). DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs. 5.8%, P for heterogeneity <0.001) and in the subgroup of studies with a mean STS score of ≥8 (1.6% vs. 6.2%, P for heterogeneity = 0.005). DAo TAVR was also associated with lower risks of permanent pacemaker implantation (12.3% vs. 20.1%, P for heterogeneity = 0.009) and valve malposition (2.0% vs. 10.2%, P for heterogeneity = 0.023) than was TAx TAVR.ConclusionsDAo TAVR increased 30-day mortality rate compared with TAx TAVR; by contrast, TAx TAVR increased postoperative stroke, permanent pacemaker implantation, and valve malposition risks compared with DAo TAVR.
Highlights
Transcatheter aortic valve replacement (TAVR) enables the safe and effective treatment of inoperable or high-surgical-risk patients with severe aortic valve disease, without using a cardiopulmonary bypass (Kodali et al, 2012; Makkar et al, 2012)
After a review of the full-text articles, we excluded 19 articles that employed duplicated cohorts, 49 that did not report the outcomes of patients who received TAx or direct aortic (DAo) transcatheter aortic valve replacement (TAVR), 13 that did not use Valve Academic Research Consortium (VARC) definitions for reporting the outcomes, one that included only TAVR with combined coronary artery bypass grafting procedure, four that used devices other than Edward or Medtronic, one that enrolled
We found that TAx TAVR was associated with a lower 30-day mortality rate, Outcome / group
Summary
Transcatheter aortic valve replacement (TAVR) enables the safe and effective treatment of inoperable or high-surgical-risk patients with severe aortic valve disease, without using a cardiopulmonary bypass (Kodali et al, 2012; Makkar et al, 2012). Randomized controlled trials have demonstrated that TAVR is an effective alternative to surgical aortic valve replacement in intermediate-risk patients (Leon et al, 2016; Reardon et al, 2017). The transfemoral route is contraindicated in nearly 10% of transcatheter aortic valve replacement (TAVR) candidates because of unsuitable iliofemoral vessels. Transaxillary (TAx) and direct aortic (DAo) routes are the principal nonfemoral TAVR routes; few studies have compared their outcomes. Methods: We performed a systematic review and meta-analysis to compare the rates of mortality, stroke, and other adverse events of TAx and DAo TAVR. DAo TAVR was associated with a significantly lower risk of stroke in the overall study population (2.6% vs 5.8%, P for heterogeneity
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