Transcatheter versus surgical aortic valve replacement in lower-risk and higher-risk patients: a meta-analysis of randomized trials

• Published in: European heart journal 2023-03, Vol.44 (10), p.836-852
• Main Authors: Ahmad, Yousif, Howard, James P, Arnold, Ahran D, Madhavan, Mahesh V, Cook, Christopher M, Alu, Maria, Mack, Michael J, Reardon, Michael J, Thourani, Vinod H, Kapadia, Samir, Thyregod, Hans Gustav Hørsted, Sondergaard, Lars, Jørgensen, Troels Højsgaard, Toff, William D, Van Mieghem, Nicolas M, Makkar, Raj R, Forrest, John K, Leon, Martin B
• Format: Article
• Language: English
• Subjects: Aortic Valve - surgery; Aortic Valve Stenosis; Heart Valve Prosthesis Implantation - methods; Humans; Randomized Controlled Trials as Topic; Risk Factors; Stroke - epidemiology; Stroke - etiology; Treatment Outcome
• ISSN: 0195-668X; 1522-9645
• DOI: 10.1093/eurheartj/ehac642

Additional randomized clinical trial (RCT) data comparing transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) is available, including longer term follow-up. A meta-analysis comparing TAVI to SAVR was performed. A pragmatic risk classification was applied, partitioning lower-risk and higher-risk patients. The main endpoints were death, strokes, and the composite of death or disabling stroke, occurring at 1 year (early) or after 1 year (later). A random-effects meta-analysis was performed. Eight RCTs with 8698 patients were included. In lower-risk patients, at 1 year, the risk of death was lower after TAVI compared with SAVR [relative risk (RR) 0.67; 95% confidence interval (CI) 0.47 to 0.96, P = 0.031], as was death or disabling stroke (RR 0.68; 95% CI 0.50 to 0.92, P = 0.014). There were no differences in strokes. After 1 year, in lower-risk patients, there were no significant differences in all main outcomes. In higher-risk patients, there were no significant differences in main outcomes. New-onset atrial fibrillation, major bleeding, and acute kidney injury occurred less after TAVI; new pacemakers, vascular complications, and paravalvular leak occurred more after TAVI. In lower-risk patients, there was an early mortality reduction with TAVI, but no differences after later follow-up. There was also an early reduction in the composite of death or disabling stroke, with no difference at later follow-up. There were no significant differences for higher-risk patients. Informed therapy decisions may be more dependent on the temporality of events or secondary endpoints than the long-term occurrence of main clinical outcomes.