R. Menon1, J.D. John1, T. Patel3, D. Patel2, B.S. Gadad5, N. Anand5, R.H. Millis4 1Malla Reddy Institute of Medical Science, Hyderabad, TELANGANA, India 2Lokmanya Tilak Municipal medical College, Mumbai, MAHARASTRA, India 3Trinity Medical Sciences University School of Medicine, Ratho Mill Kingstown, ST VINCENT, Saint Vincent and the Grenadines 4American Institute of Antigua College of Medicine, St Johns, ANTIGUA, Antigua and Barbuda 5University of Texas Rio Grande Valley School of Medicine, Department Of Medical Education, Edinburg, TX, USA
Introduction: Aortic stenosis is a debilitating heart valve disease with a poor prognosis if left untreated. Surgical aortic valve replacement (SAVR) has been the standard treatment for severe aortic stenosis. In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a promising alternative, prompting multiple updates to treatment guidelines.This study aims to compare clinical outcomes, complications, and valve durability of TAVR versus SAVR across patient risk categories, focusing on their implications for refining clinical guidelines and treatment decision-making in aortic stenosis.
Methods: We conducted a comprehensive meta-analysis and systematic review by searching PubMed, PubMed Central, and Medline databases. After rigorous screening, we identified 22 relevant articles directly addressing the research question. The analysis included a total of 8,847 patients diagnosed with severe aortic stenosis across varying operative risk categories. Baseline data were available for 4,303 TAVR patients and 4,070 SAVR patients, resulting in a robust sample size for the systematic review. Statistical analysis was performed on 7,264 selected patients based on comparable characteristics.
Results:TAVR was associated with significantly less all-cause mortality than SAVR at 30 days (RR = 0.76, 95% CI [0.65, 0.89], p = 0.0006) and one year (RR = 0.89, 95% CI [0.81, 0.99], p = 0.03). There were no significant differences in the stroke rates associated with SAVR and TAVR at 30 days (RR = 0.91, 95% CI [0.72, 1.14], p = 0.39) and one year (RR = 0.98, 95% CI [0.82, 1.19], p = 0.86). Cardiovascular death rates associated with SAVR and TAVR were also not significant different at 30 days (RR = 0.88, 95% CI [0.64, 1.20], p = 0.42) and one year (RR = 0.88, 95% CI [0.73, 1.06], p = 0.18). TAVR consistently outperformed SAVR in health status improvement, aortic valve opening, and pressure gradient, while structural valve deterioration rates were comparable between the two treatment modalities.
Conclusion:Critical appraisal of the scientific literature shows that TAVR is associated with significantly reduced all-cause mortality than SAVR, in the absence of differences in stroke and cardiovascular death rates. Evidence is also emerging that, across all risk categories, TAVR is either superior or not inferior to SAVR and long-term valve durability with TAVR is comparable to SAVR. Taken together, the findings hold promise for revising current guidelines to become more patient-centered, these findings suggest that a shared decision-making process which considers all relevant factors may be warranted to indicate TAVR as a preferred option for aortic valve replacement.