Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis

Abstract

Objective To examine the effect of transcatheter aortic valve implantation (TAVI) versus surgical replacement of an aortic valve (SAVR) in patients with severe aortic stenosis at low and intermediate risk of perioperative death.Design Systematic review and meta-analysisData sources Medline, Embase, and Cochrane CENTRAL.Study selection Randomized trials of TAVI compared with SAVR in patients with a mean perioperative risk of death <8%.Review methods Two reviewers independently extracted data and assessed risk of bias for outcomes important to patients that were selected a priori by a parallel guideline committee, including patient advisors. We used the GRADE system was used to quantify absolute effects and quality of evidence.Results 4 trials with 3179 patients and a median follow-up of two years were included. Compared with SAVR, transfemoral TAVI was associated with reduced mortality (risk difference per 1000 patients: −30, 95% confidence interval −49 to −8, moderate certainty), stroke (−20, −37 to 1, moderate certainty), life threatening bleeding (−252, −293 to −190, high certainty), atrial fibrillation (−178, −150 to −203, moderate certainty), and acute kidney injury (−53, −39 to −62, high certainty) but increased short term aortic valve reintervention (7, 1 to 21, moderate certainty), permanent pacemaker insertion (134, 16 to 382, moderate certainty), and moderate or severe symptoms of heart failure (18, 5 to 34, moderate certainty). Compared with SAVR, transapical TAVI was associated higher mortality (57, −16 to 153, moderate certainty, P=0.015 for interaction between transfemoral versus transapical TAVI) and stroke (45, −2 to 125, moderate certainty, interaction P=0.012). No study reported long term follow-up, which is particularly important for structural valve deterioration.Conclusions Many patients, particularly those who have a shorter life expectancy or place a lower value on the risk of long term valve degeneration, are likely to perceive net benefit with transfemoral TAVI versus SAVR. SAVR, however, performs better than transapical TAVI, which is of interest to patients who are not candidates for transfemoral TAVI.Systematic review registration PROSPERO CRD42016042879

Is elevation of N-terminal pro-B-type natriuretic peptide at discharge associated with 2-year composite endpoint of all-cause mortality and heart failure hospitalisation after transcatheter aortic valve implantation? Insights from a multicentre prospective OCEAN-TAVI registry in Japan

“…[3][4][5] With the expanding indication and prolongation of life expectancy after TAVI, it is speculated that risk stratification and long-term management of HF may be the next challenge facing physicians. [3][4][5][6] For example, a recent meta-analysis that predominantly included intermediate-risk patients with AS demonstrated that transfemoral TAVI is associated with more severe HF symptoms than SAVR during 2-year follow-up. 6 N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a hormone released by the cardiac ventricles as a result of elevated end-diastolic pressure overload.…”

Meta-analysis: mistake or milestone in medicine?

“…Two systematic reviews and meta-analyses (one for efficacy9 and one for prognosis10) provided the evidence for a guideline panel to make recommendations for use of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) 11. The meta-analysis assessing the efficacy of these two therapies showed that TAVI, originally designed for patients at high risk for SAVR, can be extended to low-surgical to moderate-surgical risk patients 10.…”

Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline

“…[1][2][3][4][5][6][7][8][9][10][11][12][13][14] Compared with SAVR, transfemoral TAVI reduced mortality and stroke, life threatening bleeds, atrial fibrillation, and acute kidney injury at two years, but increased heart failure, major vascular complications, pacemaker insertion, and need for aortic valve reintervention within 2 years (see infographic). 10 In contrast, transapical TAVI may increase mortality and stroke compared with the surgical approach. The results for mortality, stroke, and acute kidney injury were based on a subgroup analysis for transfemoral versus transapical approach, deemed credible by the review authors according to specific criteria.…”