Mortality risk is similar, but complications differ with TAVI and SAVR

Clinical Question

How do mortality outcomes compare between transcatheter aortic valve implantation and surgical aortic valve replacement for patients with severe aortic stenosis?

Bottom Line

The data pooled for this meta-analysis indicate that although transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) differ in types of periprocedural complications, early and midterm mortality rates are similar. The patient population in this study included patients at high surgical risk, as well as those at low to intermediate surgical risk. (LOE = 1a)

Reference

Gargiulo G, Sannino A, Capodanno D, et al. Transcatheter aortic valve implantation versus surgical aortic valve replacement. Ann Intern Med 2016;165(5):334-344.  [PMID:27272666]

Study Design

Randomized controlled trial (double-blinded)

Funding

Industry

Allocation

Uncertain

Setting

Outpatient (any)

Synopsis

These investigators searched multiple databases, including MEDLINE and the Cochrane Database of Systematic Reviews, as well as relevant websites and meeting abstracts to find randomized trials or observational matched studies that evaluated mortality outcomes for TAVI compared with SAVR in patients with severe aortic stenosis. Two reviewers independently selected studies, extracted data, and assessed the risk of bias for each included study. Of the 5 randomized trials and 31 observational studies that were selected, the risk of bias was mostly low. Although the majority of the studies included patients at high surgical risk, 2 of the randomized trials and 6 of the observational studies included patients at low to intermediate surgical risk. The mean age of patients across all the studies ranged from 70 years to 84 years and most were in New York Heart Association class III or IV. Neither early mortality (30 days or less) nor midterm mortality (1 year or less) rates differed significantly between the TAVI group and the SAVR group. In the subgroup of patients at low to intermediate surgical risk, there was a trend toward decreased early and midterm mortality in the TAVI group, but the results did not reach statistical significance. When the data from the randomized trials were stratified by TAVI approach, lower mortality was detected in patients who underwent transfemoral TAVI as compared with those who received SAVR (early mortality: odds ratio [OR] 0.68, 95% CI 0.53 - 0.87; midterm mortality: OR 0.80, 0.68 - 0.93). This difference was not seen with the use of transapical TAVI. Finally, while SAVR resulted in a higher incidence of periprocedural myocardial infarctions, major bleeds, acute kidney injuries, and new-onset atrial fibrillation, TAVI led to more pacemaker implantations, vascular complications, and paravalvular leaks.

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