Transcatheter, sutureless and conventional aortic-valve replacement: a network meta-analysis of 16,432 patients

Abstract

Background: Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR). Methods: Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes. Results: The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28-0.59) and 44% (OR 0.56, 95% CI: 0.30-0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40-0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42-0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07-0.16) and 92% (OR 0.08, 95% CI: 0.03-0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24-0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22-0.61). There were no differences in 30-day mortality or postoperative stroke between the groups. Conclusions: In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR.

Long-term outcomes of sutureless and rapid-deployment aortic valve replacement: a systematic review and meta-analysis

“…Patient selection is a critical factor given the strengths and weaknesses of each approach. A recent meta-analysis (6) compared the three modalities and revealed no differences in 30-day mortality or postoperative stroke between them, but concluded that TAVR and SURD were associated with less postoperative bleeding. SURD was also associated with less acute renal injury, but more conduction disease compared to conventional AVR.…”

Long-term outcome with sutureless valves: 12 years of Perceval experience

“…When looking at short-term outcomes, there are many studies and meta-analyses that have tried to compare standard valves, sutureless valves and TAVI among patients with a range of surgical risk levels. Recently, a network meta-analysis of 16,432 patients from seven randomized controlled trials and twenty-five propensity score-matched studies have compared all three options (1). While mortality and stroke outcomes were comparable for all three options, the sutureless AVR demonstrated less regurgitation than TAVI and less major bleeding and acute kidney injury than conventional AVR (1).…”

Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Minithoracotomy for All Comers With Aortic Valve Disease

“…18 Despite the euphoria of interventional cardiologists and TAVI experts, some drawbacks persist for this procedure including increased paravalvular regurgitation and pacemaker implantation rates, suboptimal TAVI deployment, or balloon inflation with the risk of annulus rupture, unknown long-term durability, and major vascular complications. 19,20 The above deficits of TAVI, in addition to the benefits of RAMT including the ability to remove the diseased valve leaflets, radically decalcify the annulus, and precisely size and implant the valve prosthesis under direct vision may make RAMT competitive with TAVI procedures. As a result of these benefits, we noted a low rate of paravalvular leak in the new pacemaker implantation (0.4% and 1.4%, respectively), significantly lower than those reported in the literature for TAVI.…”