Transcatheter vs. surgical aortic valve replacement and medical treatment : Systematic review and meta-analysis of randomized and non-randomized trials

Abstract

Background: Transcatheter aortic valve replacement (TAVR) has emerged as the procedure of choice for patients with severe aortic stenosis (AS) and high perioperative risk. We performed a meta-analysis to compare the mortality related to TAVR with medical therapy (MT) and surgical aortic valve replacement (SAVR).

Methods: A systematic literature search was conducted by two independent investigators from the database inception to 30 December 2014. Relative risk (RR) and odds ratio (OR) were calculated and graphically displayed in forest plots. We used I ² for heterogeneity (meta-regression) and Egger's regression test of asymmetry (funnel plots).

Results: We included 24 studies (n = 19 observational studies; n = 5 randomized controlled trials), with a total of 7356 patients in this meta-analysis. Mean age had a substantial negative impact on the long-term survival of AS patients (OR = 1.544; 95% CI: 1.25-1.90). Compared with MT, TAVR showed a statistically significant benefit for all-cause mortality at 12 months (OR = 0.68; 95% CI: 0.49-0.95). Both TAVR and SAVR were associated with better outcomes compared with MT. TAVR showed lower all-cause mortality over SAVR at 12 months (OR = 0.81; 95% CI: 0.68-0.97). The comparison between SAVR and TAVR at 2 years revealed no significant difference (OR = 1.09; 95% CI: 1.01-1.17).

Conclusion: In AS, both TAVR and SAVR provide a superior prognosis to MT and, therefore, MT is not the preferred treatment option for AS. Furthermore, our data show that TAVR is associated with lower mortality at 12 months compared with SAVR. Further studies are warranted to compare the long-term outcome of TAVR versus SAVR beyond a 2-year follow-up period.

Keywords: Aortic stenosis; Mortality; Optimal medical treatment; Surgical aortic valve replacement; Transcatheter aortic valve replacement.