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. 2025 May 20:S1553-8389(25)00249-0.
doi: 10.1016/j.carrev.2025.05.021. Online ahead of print.

TAVR vs. SAVR for severe aortic stenosis in the low and intermediate surgical risk population: An updated meta-analysis, meta-regression, and trial sequential analysis

Mrinal Murali Krishna  1 , Meghna Joseph  2 , Chidubem Ezenna  3 , Vinicius Pereira  4 , Raiza Rossi  5 , Zafer Akman  6 , Muni Rubens  7 , Vaikom S Mahadevan  8 , Michael G Nanna  9 , Andrew M Goldsweig  10
Affiliations

TAVR vs. SAVR for severe aortic stenosis in the low and intermediate surgical risk population: An updated meta-analysis, meta-regression, and trial sequential analysis

Mrinal Murali Krishna et al. Cardiovasc Revasc Med. .

Abstract

Background: Guidelines recommend transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for patients of age > 65 years. The relative risks and benefits of TAVR vs. SAVR in low and intermediate surgical risk remain incompletely described.

Methods: A systematic search of PubMed, Scopus, and Cochrane Central databases identified randomized controlled trials (RCTs) comparing clinical outcomes of TAVR vs. SAVR in low and intermediate surgical risk.

Results: Ten RCTs (9239 patients, TAVR 50.8 %) were included. TAVR was associated with lower rates of all-cause death or stroke at 30-day (rate ratio [RR] 0.70; 95%CI 0.55-0.89; p = 0.003; I2 = 26 %) and 1-year (RR 0.77; 95%CI 0.60-0.98; p = 0.033; I2 = 54 %) follow-up. Bleeding complications, new-onset atrial fibrillation (AF), acute kidney injury (AKI), and severe patient-prosthesis mismatch (PPM) were lower with TAVR at 30 days and 1-year. Permanent pacemaker implantation, aortic valve reintervention, major vascular complications, and paravalvular leak (PVL) were significantly higher with TAVR at 30-day and 1-year follow-ups. Rates of all-cause death, stroke, MI, endocarditis, and rehospitalization were comparable between the groups at 30-day and 1-year follow-up.

Conclusion: In patients with severe AS and low to intermediate surgical risk, TAVR is associated with reduced rates of all-cause death or stroke, bleeding, new-onset AF, AKI, and severe PPM compared to SAVR. However, despite these short-term benefits, higher rates of permanent pacemaker implantation, PVL, and reintervention raise significant concerns about the long-term safety of TAVR, particularly for younger, lower-risk patients.

Keywords: Aortic stenosis; Low and intermediate surgical risk; Surgical aortic valve replacement; Transcatheter aortic valve replacement; Trial sequential analysis; meta-regression.

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Conflict of interest statement

Declaration of competing interest Dr. Goldsweig reports consulting for Philips and Conformal Medical and speaking for Philips. Dr. Nanna reports consulting for Heartflow, Merck, and Novo Nordisk as well as research support from the American College of Cardiology Foundation supported by the George F. and Ann Harris Bellows Foundation, the Patient-Centered Outcomes Research Institute (PCORI), the Yale Claude D. Pepper Older Americans Independence Center (P30AG021342), and the National Institute on Aging (K76AG088428). No other authors report relationships with industry to disclose.

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