Systematic review, meta-analysis of cusp-overlap vs. three-cusp coplanar approaches in self-expandable transcatheter aortic valve replacement

BACKGROUND: The cusp-overlap technique (COT) is an alternative fluoroscopic approach to the standard three-cusp technique (ST) in self-expandable transcatheter aortic valve replacement (TAVR). It may improve implantation depth and reduce conduction disturbances, but its overall clinical benefit remains unclear. OBJECTIVES: To compare the safety and efficacy of COT vs. ST in terms of mortality, conduction disturbances, permanent pacemaker implantation (PPI), and cerebrovascular accidents (CVA). METHODS: This systematic review and meta-analysis followed PRISMA guidelines. PubMed, Cochrane, Scopus, Embase, and Web of Science were searched up to October 2025. Studies comparing COT and ST were included. Data extraction and risk-of-bias assessment were performed independently. Meta-analysis was conducted using R with fixed- and random-effects models. Outcomes included mortality (by follow-up), conduction disturbances, PPI, and CVA. The protocol was registered in PROSPERO (CRD420251156402). RESULTS: Eighteen studies were analyzed, with patient numbers varying by outcome (mortality: 5,984 patients; conduction disturbances: 7,200 patients; PPI: 5,712 patients; CVA: 4,066 patients). COT significantly reduced mortality compared with ST (OR: 0.60, 95% CI: 0.40-0.88; p = 0.010; I 2 = 0%), with the strongest effect observed at 30 days. Conduction disturbances were also lower with COT (OR: 0.62, 95% CI: 0.48-0.82; p = 0.0006; I 2 = 77.7%), driven by reductions in both complete atrioventricular block and left bundle branch block. The risk of PPI was markedly reduced with COT (OR: 0.50, 95% CI: 0.39-0.63; p < 0.0001; I 2 = 23.0%). In contrast, there was no significant difference in CVA between groups (random-effects OR: 1.05, 95% CI: 0.73-1.51; p = 0.78; I 2 = 0%). CONCLUSION: COT in self-expandable TAVR is associated with lower rates of conduction disturbances and PPI, and reduced short-term mortality, without increasing cerebrovascular risk. While these findings are consistent and clinically plausible, the overall certainty of evidence is limited. COT appears to be a promising procedural refinement, but further randomized studies are needed to confirm long-term benefits. SYSTEMATIC REVIEW REGISTRATION: identifier CRD420251156402.