Longer-term and landmark analysis of transcatheter vs. surgical aortic-valve implantation in severe aortic stenosis: a meta-analysis.

Abstract

Background: Previous reports of longer-term outcomes of transcatheter aortic valve implantation (TAVI) focus on higher risk patients and suggest potential temporal changes.

Aims: To evaluate the longer-term and temporal performances of TAVI compared to surgical aortic valve replacement (SAVR).

Methods: Randomized controlled trials reporting outcomes with at least 1-year follow-up. The primary outcome was the composite of all-cause death or disabling stroke.

Results: We included 8 trials with 8,749 patients. TAVI was associated with a higher risk of longer-term (5-year) primary outcome compared to SAVR among higher-risk [odds ratio (OR), 1.25; 95% CI, 1.07-1.47] but not lower-risk participants [1.0 (0.77-1.29)]. However, a significant temporal interaction was detected in both risk profiles. TAVI with balloon-expandable valves was associated with a higher risk of longer-term primary outcome compared to SAVR [1.38 (1.2-1.6)], whereas no statistical difference was found with self-expanding valves [1.03 (0.89-1.19)]. There was a significant interaction between the two valve systems, and a temporal interaction was detected in both systems. Overall landmark analysis revealed a lower risk in TAVI within the initial 30 days [0.76 (0.6, 0.96)], comparable between 30 days to 2 years [1.04 (0.85, 1.28)], and higher beyond 2 years [1.36 (1.15-1.61)]. Analysis for all-cause death generated largely similar results.

Conclusions: TAVI was associated with a higher longer-term risk of primary outcome compared to SAVR in higher-risk patients and with balloon-expandable valves. However, a characteristic temporal interaction was documented in all subgroups. Future studies are warranted to test these findings.