Comparative effectiveness of transcatheter vs surgical aortic valve replacement: A systematic review and meta-analysis.

Abstract

Background: The management of severe symptomatic aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), offering a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, the comparative safety and efficacy of these interventions remain subjects of ongoing investigation.

Aim: To compare the clinical outcomes and safety of TAVR vs SAVR in patients with severe symptomatic aortic stenosis.

Methods: A systematic review and meta-analysis were conducted according to PRISMA guidelines. Randomized controlled trials (RCTs) comparing TAVR and SAVR were identified from databases including PubMed, Scopus, and Web of Science up to May 31, 2024. Data were extracted on clinical outcomes, including mortality, procedural complications, and post-procedure adverse events. Risk ratios (RRs) with 95%CIs were calculated using a random-effects model.

Results: A total of 10 RCTs were included. TAVR demonstrated a significantly lower risk of acute kidney injury (RR: 0.33; 95%CI: 0.25-0.44), major bleeding (RR: 0.37; 95%CI: 0.30-0.46), and new-onset atrial fibrillation (RR: 0.44; 95%CI: 0.34-0.57) compared to SAVR. However, TAVR was associated with higher risks of new permanent pacemaker implantation (RR: 3.49; 95%CI: 2.77-4.39), major vascular complications (RR: 2.47; 95%CI: 1.91-3.21), and paravalvular leaks (RR: 4.15; 95%CI: 3.14-5.48). Mortality at 30 days was comparable (RR: 0.95; 95%CI: 0.78-1.15), but long-term mortality was slightly higher with TAVR in some analyses (RR: 1.23; 95%CI: 1.01-1.49). Rates of stroke (RR: 0.97; 95%CI: 0.81-1.17) and myocardial infarction (RR: 0.91; 95%CI: 0.67-1.24) were similar between the groups.

Conclusion: TAVR offers a less invasive option with significant benefits in reducing acute kidney injury, major bleeding, and new-onset atrial fibrillation, making it particularly advantageous for high-risk surgical candidates. However, higher risks of permanent pacemaker implantation, vascular complications, and paravalvular leaks highlight the need for individualized patient selection and shared decision-making to optimize outcomes.