A Bayesian meta-analysis of transcatheter versus surgical aortic valve replacement in patients with small aortic annulus.

Abstract

Background: Small aortic annulus (SAA) is associated to suboptimal results after aortic valve replacement. The optimal treatment for aortic disease in SAA remains unclear.

Methods: We conducted a systematic review and Bayesian random-effects meta-analysis to compare transcatheter (TAVR) versus surgical aortic valve replacement (SAVR) in patients with small aortic annulus. A comprehensive search of PubMed, Scopus, and Cochrane Library was performed through May 2024. Binary outcomes were synthesized using a binomial-normal hierarchical model to estimate posterior distributions of log odds ratios (log OR) and corresponding 95 % credible intervals (CrIs). Posterior probabilities of treatment effects were calculated to assess the certainty of benefit or harm. All statistical analyses were performed using R version 4.5.0.

Results: Nine studies comprising 2548 patients (50.9 % TAVR) were included. TAVR was associated with reduced risk of severe patient-prosthesis mismatch (OR 0.47; 95 % CrI 0.31-0.72; posterior probability of benefit 99.8 %) and moderate mismatch (OR 0.56; 95 % CrI 0.40-0.79; posterior probability 99.7 %). In contrast, SAVR was associated with lower risk of moderate/severe aortic regurgitation (OR 4.74; 95 % CrI 2.43-9.27; posterior probability of harm with TAVR 98.1 %) and permanent pacemaker implantation (OR 2.66; 95 % CrI 1.69-4.20; posterior probability of harm with TAVR 98.5 %). No meaningful differences were observed for stroke at 30 days (OR 1.51; 95 % CrI 0.69-3.36) or all-cause mortality at 1 year (OR 0.78; 95 % CrI 0.51-1.17).

Conclusions: TAVR is superior to SAVR regarding severe and moderate PPM in SAA patients. SAVR is associated with lower risk of aortic regurgitation and new pacemaker implant, with no significant differences in mortality and stroke.