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. 2016 Sep 28:354:i5130.
doi: 10.1136/bmj.i5130.

Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis

Reed A Siemieniuk  1 , Thomas Agoritsas  2 , Veena Manja  3 , Tahira Devji  4 , Yaping Chang  4 , Malgorzata M Bala  5 , Lehana Thabane  4 , Gordon H Guyatt  4
Affiliations

Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis

Reed A Siemieniuk et al. BMJ. .

Abstract

Objective: To examine the effect of transcatheter aortic valve implantation (TAVI) versus surgical replacement of an aortic valve (SAVR) in patients with severe aortic stenosis at low and intermediate risk of perioperative death.

Design: Systematic review and meta-analysis DATA SOURCES: Medline, Embase, and Cochrane CENTRAL.

Study selection: Randomized trials of TAVI compared with SAVR in patients with a mean perioperative risk of death <8%.

Review methods: Two reviewers independently extracted data and assessed risk of bias for outcomes important to patients that were selected a priori by a parallel guideline committee, including patient advisors. We used the GRADE system was used to quantify absolute effects and quality of evidence.

Results: 4 trials with 3179 patients and a median follow-up of two years were included. Compared with SAVR, transfemoral TAVI was associated with reduced mortality (risk difference per 1000 patients: -30, 95% confidence interval -49 to -8, moderate certainty), stroke (-20, -37 to 1, moderate certainty), life threatening bleeding (-252, -293 to -190, high certainty), atrial fibrillation (-178, -150 to -203, moderate certainty), and acute kidney injury (-53, -39 to -62, high certainty) but increased short term aortic valve reintervention (7, 1 to 21, moderate certainty), permanent pacemaker insertion (134, 16 to 382, moderate certainty), and moderate or severe symptoms of heart failure (18, 5 to 34, moderate certainty). Compared with SAVR, transapical TAVI was associated higher mortality (57, -16 to 153, moderate certainty, P=0.015 for interaction between transfemoral versus transapical TAVI) and stroke (45, -2 to 125, moderate certainty, interaction P=0.012). No study reported long term follow-up, which is particularly important for structural valve deterioration.

Conclusions: Many patients, particularly those who have a shorter life expectancy or place a lower value on the risk of long term valve degeneration, are likely to perceive net benefit with transfemoral TAVI versus SAVR. SAVR, however, performs better than transapical TAVI, which is of interest to patients who are not candidates for transfemoral TAVI.

Systematic review registration: PROSPERO CRD42016042879.

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Conflict of interest statement

All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 PRISMA flow diagram of studies included in review of transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk
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Fig 2 Kaplan-Meier survival curve for transfemoral transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) for severe aortic stenosis. NOTION and PARTNER 2A provided data to 24 months, and US Pivotal provided data to 36 months
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Fig 3 Kaplan-Meier survival curve for transapical transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) for severe aortic stenosis. STACCATO provided data to 3 months, and PARTNER 2A provided data to 24 months
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Fig 4 Forest plot for relative risk of stroke at longest follow-up for transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) for severe aortic stenosis, by valve approach. P=0.012 for interaction
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Fig 5 Forest plot for relative risk of acute kidney injury at longest follow-up for transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) for severe aortic stenosis, by valve approach. P<0.001 for interaction
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Fig 6 Forest plot for relative risk of life threatening or disabling bleeding at longest follow-up for transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) for severe aortic stenosis, by valve approach. P=0.037 for interaction
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Fig 7 Forest plot for permanent pacemaker insertion at longest follow-up for transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR) for severe aortic stenosis
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References

    1. Turina J, Hess O, Sepulcri F, Krayenbuehl HP. Spontaneous course of aortic valve disease. Eur Heart J 1987;8:471-83.pmid:3609042. - PubMed
    1. HCUPnet. Healthcare Cost and Utilization Project Rockville, MD Agency for Healthcare Research and Quality. [Available from: http://hcupnet.ahrq.gov/. - PubMed
    1. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet 2006;368:1005-11. 10.1016/S0140-6736(06)69208-8 pmid:16980116. - DOI - PubMed
    1. Holmes DR Jr, , Nishimura RA, Grover FL, et al. STS/ACC TVT Registry. Annual Outcomes With Transcatheter Valve Therapy: From the STS/ACC TVT Registry. J Am Coll Cardiol 2015;66:2813-23. 10.1016/j.jacc.2015.10.021 pmid:26652232. - DOI - PubMed
    1. Vahanian A, Alfieri O, Andreotti F, et al. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) European Association for Cardio-Thoracic Surgery (EACTS). Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-96. 10.1093/eurheartj/ehs109 pmid:22922415. - DOI - PubMed