ObjectiveTo systematically compare the perioperative efficacy and safety of transcatheter aortic valve replacement (TAVR) via peripheral arterial versus transapical approaches for patients with pure native aortic regurgitation (PNAR). MethodsPatients with PNAR who underwent TAVR in the Department of Cardiac Surgery, The Second Hospital of Hebei Medical University from 2015 to 2023 were retrospectively enrolled and divided into a peripheral group and a transapical group according to surgical approach. The baseline data, intraoperative procedural parameters, complication profiles and postoperative recovery indicators were collected for intergroup comparative analysis. ResultsA total of 82 patients were enrolled, including 40 patients in the peripheral group [28 males, 12 females, aged (68.25±7.62) years] and 42 patients in the transapical group [30 males, 12 females, aged (67.81±8.15) years]. No perioperative death occurred in either group. The procedural success rate and device success rate were significantly lower in the peripheral group than those in the transapical group (all P<0.05), while the overall success rate showed no statistically significant intergroup difference (P=0.506). There were no significant differences between the two groups in the incidences of moderate or greater paravalvular regurgitation, coronary artery obstruction, new-onset stroke, peripheral vascular complications or conversion to open thoracotomy (all P>0.05). The rates of valve-in-valve implantation, new-onset transient atrioventricular block and permanent pacemaker implantation were remarkably higher in the peripheral group (all P<0.05). The duration of ICU stay and postoperative hospital stay were markedly shorter in the peripheral group (all P<0.05). Repeated-measures analysis of variance with Greenhouse-Geisser correction for sphericity assumption revealed statistically significant main effects of time, main intergroup effects and group-time interaction effects for two normally distributed cardiac function indicators including left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDD) (all P<0.05). Patients in the peripheral group suffered more severe baseline cardiac impairment and higher preoperative surgical risk stratification, and achieved prominent catch-up improvement in LVEF and LVEDD after surgery; the levels of the two indicators were nearly equivalent between the two groups on postoperative day 7. N-terminal pro-B-type natriuretic peptide decreased significantly in both groups after surgery with a larger decline magnitude in the peripheral group, and the levels of the two groups became comparable on postoperative day 7. ConclusionBoth peripheral arterial access and transapical TAVR are safe and effective for PNAR treatment with equivalent overall perioperative success rates. Surgical approach should be selected individually based on aortic root anatomy, baseline cardiac function and surgical risk stratification in clinical practice. Clinicians should stay alert to potential long-term risks of peripheral approach, including compromised valve durability and limited accessibility to subsequent coronary intervention.