Abstract Body (Do not enter title and authors here): Background and Aims
Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe aortic stenosis, particularly prevalent in elderly patients. These patients often present with coexisting coronary artery disease (CAD) due to shared risk factors. There is evidence suggesting that underlying CAD may result in poorer outcomes for patients undergoing TAVR. Chronic total occlusion (CTO), representing a severe manifestation of CAD, could therefore be hypothesized to worsen prognosis in TAVR patients, although data supporting this hypothesis are limited. Our meta-analysis aims to consolidate all available data concerning patients undergoing TAVR with concurrent CTO.

Methods
We conducted a thorough literature search across major bibliographic databases, including PubMed, Embase, Cochrane Library, and SCOPUS, from their inception until May 15, 2024, to identify studies comparing outcomes of TAVR in patients with and without CTO. Pooled odds ratios (OR) with 95% confidence intervals (CIs) were calculated using the random-effects model via Comprehensive Meta-Analysis Software. The primary outcome assessed was in-hospital mortality, with several secondary endpoints also evaluated. Statistical significance was determined at p<0.05.

Results
Eight studies, encompassing a total of 540,910 patients undergoing TAVR (11,679 with CTO; 529,231 without CTO), were included in this meta-analysis. TAVR in patients with CTO was associated with significantly increased odds of in-hospital mortality (OR: 1.25; 95% CI: 1.05, 1.49; p=0.011; I²=0%) and acute myocardial infarction (periprocedural) (OR: 1.68; 95% CI: 1.48, 1.91; p<0.001; I²=0%). However, no significant difference was observed in all-cause mortality (OR: 1.18; 95% CI: 0.71, 1.96; p=0.525; I²=59.37%), acute kidney injury (OR: 1.32; 95% CI: 0.94, 1.85; p=0.11; I²=72.12%), and stroke (OR: 1.06; 95% CI: 0.89, 1.28; p=0.509; I²=0%) (see Figures 1 and 2).

Conclusion
CTO emerges as a substantial risk factor for patients undergoing TAVR, elevating the risk of in-hospital mortality and acute myocardial infarction. Considering a heart team's multidisciplinary approach in patients with underlying CTO may be advisable during TAVR, allowing for a comprehensive assessment of the benefits versus risks of revascularization prior to TAVR.