Transcatheter vs surgical aortic-valve replacement in low- to intermediate-surgical-risk candidates: A meta-analysis and systematic review

Abstract

The American and European expert documents recommend transcatheter aortic valve replacement (TAVR) for inoperable or high-surgical-risk patients with severe aortic stenosis. In comparison, efficacy of TAVR is relatively less studied in low- to intermediate-surgical-risk patients. We sought to discover whether TAVR can be as effective as surgical aortic valve replacement (SAVR) in low- to intermediate-surgical-risk candidates. Four randomized clinical trials (RCTs) and 8 prospective matched studies were selected using PubMed/MEDLINE, Embase, and Cochrane Library (inception: March 2017). Results were reported as random-effects odds ratio (OR) with 95% confidence interval (CI). Among 9851 patients, analyses of RCTs showed that all-cause mortality was comparable between TAVR and SAVR (short term, OR: 1.19, 95% CI: 0.86-1.64, P = 0.30; mid-term, OR: 0.97, 95% CI: 0.75-1.26, P = 0.84; and long term, OR: 0.97, 95% CI: 0.81-1.16, P = 0.76). The analysis restricted to matched studies showed similar outcomes. In the analysis stratified by study design, no significant differences were noted in the RCTs for stroke, whereas TAVR was better than SAVR in matched studies at short term only (OR: 0.46, 95% CI: 0.33-0.65, P < 0.001). TAVR is associated with reduced risk of acute kidney injury and new-onset atrial fibrillation (P < 0.05). However, increased incidence of permanent pacemaker implantation and paravalvular leaks was observed with TAVR. TAVR can provide similar mortality outcome compared with SAVR in low- to intermediate-surgical-risk patients with critical aortic stenosis. However, both procedures are associated with their own array of adverse events.

Keywords: Meta-analysis; Surgical Aortic Valve Replacement; Transcatheter Aortic Valve Replacement.

Figure 1

Search strategy. Study‐selection process through Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA)

Figure 2

Forest plot for all‐cause mortality. Abbreviations: CI, confidence interval; NOTION, Nordic Aortic Valve Intervention; PARTNER, Placement of Aortic Transcatheter Valves; RCT, randomized clinical trial; SAVR, surgical aortic valve replacement; STACCATO, A Prospective, Randomized Trial of Transapical Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement in Operable Elderly Patients with Aortic Stenosis; SURTAVI, Surgical Replacement and Transcatheter Aortic Valve Implantation; TAVR, transcatheter aortic valve replacement

Figure 3

Forest plot for cardiac mortality. Abbreviations: CI, confidence interval; NOTION, Nordic Aortic Valve Intervention; PARTNER, Placement of Aortic Transcatheter Valves; RCT, randomized clinical trial; SAVR, surgical aortic valve replacement; SURTAVI, Surgical Replacement and Transcatheter Aortic Valve Implantation; TAVR, transcatheter aortic valve replacement

Figure 4

Forest plot for myocardial infarction. Abbreviations: CI, confidence interval; NOTION, Nordic Aortic Valve Intervention; PARTNER, Placement of Aortic Transcatheter Valves; RCT, randomized clinical trial; SAVR, surgical aortic valve replacement; SURTAVI, Surgical Replacement and Transcatheter Aortic Valve Implantation; TAVR, transcatheter aortic valve replacement

Figure 5

Forest plot for disabling stroke. Abbreviations: CI, confidence interval; NOTION, Nordic Aortic Valve Intervention; PARTNER, Placement of Aortic Transcatheter Valves; RCT, randomized clinical trial; SAVR, surgical aortic valve replacement; STACCATO, A Prospective, Randomized Trial of Transapical Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement in Operable Elderly Patients with Aortic Stenosis; SURTAVI, Surgical Replacement and Transcatheter Aortic Valve Implantation; TAVR, transcatheter aortic valve replacement