Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients

Dhaval Kolte; Gus J Vlahakes; Igor F Palacios; Rahul Sakhuja; Jonathan J Passeri; Ignacio Inglessis; Sammy Elmariah

doi:10.1016/j.jacc.2019.06.076

Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients

J Am Coll Cardiol. 2019 Sep 24;74(12):1532-1540. doi: 10.1016/j.jacc.2019.06.076.

Authors

Dhaval Kolte¹, Gus J Vlahakes², Igor F Palacios¹, Rahul Sakhuja¹, Jonathan J Passeri¹, Ignacio Inglessis¹, Sammy Elmariah³

Affiliations

¹ Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
² Cardiac Surgery Division, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
³ Cardiology Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: selmariah@mgh.harvard.edu.

PMID: 31537261
DOI: 10.1016/j.jacc.2019.06.076

Abstract

Background: Transcatheter aortic valve replacement (TAVR) has emerged as a safe and effective therapeutic option for patients with severe aortic stenosis (AS) who are at prohibitive, high, or intermediate risk for surgical aortic valve replacement (SAVR). However, in low-risk patients, SAVR remains the standard therapy in current clinical practice.

Objectives: This study sought to perform a meta-analysis of randomized controlled trials (RCTs) comparing TAVR versus SAVR in low-risk patients.

Methods: Electronic databases were searched from inception to March 20, 2019. RCTs comparing TAVR versus SAVR in low-risk patients (Society of Thoracic Surgeons Predicted Risk of Mortality [STS-PROM] score <4%) were included. Primary outcome was all-cause death at 1 year. Random-effects models were used to calculate pooled risk ratio (RR) and corresponding 95% confidence interval (CI).

Results: The meta-analysis included 4 RCTs that randomized 2,887 patients (1,497 to TAVR and 1,390 to SAVR). The mean age of patients was 75.4 years, and the mean STS-PROM score was 2.3%. Compared with SAVR, TAVR was associated with significantly lower risk of all-cause death (2.1% vs. 3.5%; RR: 0.61; 95% CI: 0.39 to 0.96; p = 0.03; I² = 0%) and cardiovascular death (1.6% vs. 2.9%; RR: 0.55; 95% CI: 0.33 to 0.90; p = 0.02; I² = 0%) at 1 year. Rates of new/worsening atrial fibrillation, life-threatening/disabling bleeding, and acute kidney injury stage 2/3 were lower, whereas those of permanent pacemaker implantation and moderate/severe paravalvular leak were higher after TAVR versus SAVR. There were no significant differences between TAVR versus SAVR for major vascular complications, endocarditis, aortic valve re-intervention, and New York Heart Association functional class ≥II.

Conclusions: In this meta-analysis of RCTs comparing TAVR versus SAVR in low-risk patients, TAVR was associated with significantly lower risk of all-cause death and cardiovascular death at 1 year. These findings suggest that TAVR may be the preferred option over SAVR in low-risk patients with severe AS who are candidates for bioprosthetic AVR.

Keywords: death; low risk; surgical aortic valve replacement; transcatheter aortic valve implantation; transcatheter aortic valve replacement.

Publication types

Comparative Study
Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Aortic Valve / surgery*
Aortic Valve Stenosis / surgery*
Heart Valve Prosthesis Implantation / methods*
Humans
Randomized Controlled Trials as Topic
Risk Assessment
Severity of Illness Index
Transcatheter Aortic Valve Replacement