Transcatheter Versus Surgical Aortic Valve Replacement: An Updated Systematic Review and Meta-Analysis With a Focus on Outcomes by Sex

Abstract

Background and Aims Women at increased surgical risk have been shown to have better outcomes with transcatheter aortic valve implantation (TAVI) as compared to surgical valve replacement (SAVR). With the scope of TAVI moving into low-surgical risk patients, we aimed to update the current literature to include the new low-risk randomised controlled trial (RCT) data in investigating outcomes by sex. Methods We systematically searched MEDLINE (Ovid), PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and reference lists for relevant RCTs comparing TAVI to SAVR published prior to 4 May 2020. Data extraction was performed by two independent authors and included trial design details, baseline characteristics and outcome data stratified by sex. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. Quantitative synthesis of pooled data was performed using Mantel-Haenszel fixed or random effects model. Q-statistic and the I 2 test were used for assessment of heterogeneity. Results Our search yielded eight RCTs included in the final quantitative synthesis. The overall pooled cohort was 8,040, of whom 41.4% were female. Women had significantly lower rates of one-year all-cause mortality (12.2% vs 17.7%, pooled OR 0.59, 95% CI 0.40-0.86) and one-year composite endpoint (9.7% vs 12.4%, pooled OR 0.73, 95% CI 0.58-0.92) with TAVI as compared to SAVR. The selective mortality benefit with TAVI over SAVR in women did not persist to 5 years (pooled HR 1.01, 95% CI 0.87-1.17). At 30 days, women demonstrated lower rates of major bleeding and acute kidney injury following TAVI compared to SAVR. For men, these outcomes were similar regardless of type of intervention. Both sexes were at increased risk of major vascular complications with TAVI as compared to SAVR, however women demonstrated nearly double the odds of major vascular complication with TAVI compared to men. Conclusion Our updated meta-analysis demonstrates that at one-year women undergoing TAVI have significantly lower mortality and better safety outcomes compared to those undergoing SAVR. These benefits are not seen in men. In the new low-risk era, these results are ever more important for guiding appropriate patient selection.

Gender Differences after Transcatheter Aortic Valve Replacement (TAVR): Insights from the Italian Clinical Service Project

“…Moreover, it has been demonstrated that women present a significant improvement of LVEF after TAVR [ 20 ], which may account for superior survival. Our 1-year death rate (11.5%) is in line with that reported by PARTNER II trial (12.3%), confirmed by a recent meta-analysis [ 2 , 21 ]. Women of our cohort have been associated with better survival also at 3-year, as similarly reported in a recent publication [ 22 ].…”

One-Year Outcomes after Surgical versus Transcatheter Aortic Valve Replacement with Newer Generation Devices

“…Similar findings were observed at 2-year follow-up. The findings have been confirmed by a more recent meta-analysis by Dagan et al [23], and this reflects the increased operative risk of women undergoing cardiac surgery [24]. Previous studies did not document a clear benefit of TAVR in terms of survival in high-risk patients, but there is a lack of specific data in patients treated with new-generation devices.…”

Implante Valvar Transcateter em Pacientes com Estenose Valvar Aórtica: Uma Overview de Revisões Sistemáticas e Metanálise Incluindo Múltiplas Populações

“…Duas metanálises compararam as diferenças de sexo nos desfechos de TAVR e SAVR, com níveis de confiança moderados na escala AMSTAR-2 ( Tabela Suplementar 3 ). 19 , 20 Os estudos identificaram que o TAVR em mulheres estava associado a uma redução no risco de morte e IRA, mas não em homens. No entanto, o TAVR aumentou significativamente o risco de IMD em homens, mas não em mulheres.…”