Transcatheter versus minimally invasive surgical aortic valve replacement: A propensity score-matched analysis in low-risk patients

Abstract

Objective

Minimally invasive aortic valve replacement (MIAVR) and transcatheter aortic valve replacement (TAVR) represent less-invasive alternatives to conventional surgical aortic valve replacement. In contrast to Society of Thoracic Surgeons (STS) Database data revealing <10% of all surgical aortic valve replacement procedures are performed via a minimally invasive approach, our center performs a high volume of MIAVR procedures. This propensity-score matched study aims to compare the outcomes of MIAVR versus TAVR in low-risk patients (STS Predicted Risk of Mortality <4%).

Methods

We identified 476 low-risk patients who underwent MIAVR via a right anterolateral minithoracotomy and 679 low-risk patients who underwent TAVR at our institution between 2017 and 2024. In a total of 1155 cases, propensity score analysis performed at a ratio of 1:1 yielded 295 matched pairs.

Results

The matched groups had similar baseline characteristics aside from a higher proportion of tricuspid valves in the TAVR group and greater rates of aortic regurgitation in the MIAVR group. The baseline STS scores were also higher in the TAVR group (1.84 vs 1.69; P = .030), although still below the low-risk threshold (STS-PROM <4.0). Postoperatively, patients in the MIAVR group experienced lower rates of permanent pacemaker implantation (0.4% vs 7.8%; P < .001), aortic regurgitation (0.3% vs 5.4%; P < .001), and paravalvular leak (0.0% vs 5.8%; P < .001). Patients undergoing MIAVR had longer hospital lengths of stay (6.23 vs 2.07; P < .001) and higher aortic valve mean gradients (7.29 vs 6.04 mm Hg; P = .004). There was no significant difference in early mortality or stroke rates between the 2 groups.

Conclusions

To our knowledge, this is the first propensity-score matched comparison of clinical outcomes in low-risk patients undergoing MIAVR versus TAVR, revealing that MIAVR could provide lower rates of permanent pacemaker implantation, paravalvular leak, and aortic regurgitation, without any increase in short-term mortality or stroke. Future prospective or randomized controlled trials are needed to validate these results.