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.

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.