Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression

Absract

Background

Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks.

Methods

We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time.

Results

A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4–5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement.

Conclusions

TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

BRIEF SUMMARY

Transcatheter aortic valve implantation (TAVI) was associated with increased all-cause mortality at longer periods of follow-up irrespective of surgical risk. Aortic regurgitation, paravalvular regurgitation, major vascular complications, and pacemaker placement favoured surgical aortic valve replacement (SAVR) over TAVI. TAVI remained superior to SAVR in major bleeding and renal failure events. Long-term data on newer generation valves and up-to-date implantation techniques may provide better durability and improved outcomes after TAVI.

HIGHLIGHTS

• TAVI had higher mortality at longer follow up irrespective of surgical risk.

• Aortic regurgitation and paravalvular regurgitation favour SAVR over TAVI.

• Major vascular complications and pacemaker placement also favour SAVR over TAVI.

• TAVI remains superior to SAVR in major bleeding and renal failure events.

• Long-term data on newer generation valves and up-to-date techniques are needed.

Keywords:

• TAVR
• TAVI
• SAVR
• aortic stenosis
• mortality
• meta-analysis

Author contributions

Dae Yong Park: conceptualisation, methodology, software, validation, formal analysis, investigation, resources, data curation, original draft preparation, review and revision, visualisation

Seokyung An: methodology, software, validation, formal analysis, investigation, resources, data curation, original draft preparation, review and revision, visualisation

Kameel Kassab: review and revision

Neeraj Jolly: review and revision

Steve Attanasio: review and revision

Ray Sawaqed: validation, review and revision

Saurabh Malhotra: review and revision

Rami Doukky: validation, review and revision, supervision

Aviral Vij: conceptualisation, methodology, validation, original draft preparation, review and revision, supervision, project administration

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data included in this study can be found as published papers in public medical databases.

Additional information

Funding

No funding was received in conducting this study.