Transcatheter versus surgical aortic valve replacement in patients with non-high surgical risk severe aortic stenosis: A systematic review.

OBJECTIVE: Transcatether aortic valve replacement (TAVR) has emerged as an acceptable alternative to surgical aortic valve replacement (SAVR) in patients with high-risk surgical profile. In this analysis, we compare both approaches in non-high surgical risk severe aortic stenosis.

METHODS: Only studies comparing SAVR and TAVR and enrolling patients with low-intermediate risk were included from January 2000 through May 2016. Primary endpoints were assessed at 1 and 12months including: mortality, cerebrovascular accident (CVA) and myocardial infarction (MI). Secondary endpoints at 1month included: bleeding, acute kidney injury, new permanent pacemaker implantation and vascular access site complications.

RESULTS: A total of 5223 patients from 8 studies were included (4 prospective and 4 retrospective). There were no significant differences between TAVR and SAVR at one month in terms of mortality (risk ratio RR 0.91, 95% CI: 0.68 to 1.20), or CVA (RR 0.91, 95% CI 0.68 to 1.21). However, MI was lower in the TAVR group (RR 0.58, 95% CI 0.34 to 0.99). At 12months, there was no significant difference between strategies in terms of mortality (RR 0.98, 95% CI 0.84-1.13), CVA (RR1.07, 95% CI 0.85-1.33) or MI (RR 0.78, 95% CI 0.53-1.15). With regard to secondary outcomes, TAVR was associated with lower rates of bleeding (RR 0.44, 95% CI 0.22-0.88) and acute kidney injury (RR 0.54, 95% CI 0.31-0.93) but higher need for new permanent pacemaker implantation (RR 2.99, 95% CI 1.51-5.94) and high rate of vascular access site complications (RR 9.08, 95% CI 2.03-40.66).

CONCLUSION: In severe AS patients with non-high surgical risk, TAVR has lower risk of MI at one month, but both TAVR and SAVR yielded similar outcomes at one month in terms of mortality and CVA and at 12months in terms of mortality, CVA and MI. In regard to secondary outcomes at one month, TAVR has lower rates of bleeding and acute kidney injury, and higher rates of need for new permanent pacemakers and high rate of vascular access site complications.