Vinod H Thourani1, J James Edelman2, Sari D Holmes3, Tom C Nguyen4, John Carroll5, Michael J Mack6, Samir Kapadia7, Gilbert H L Tang8, Susheel Kodali9, Tsuyoshi Kaneko10, Christopher U Meduri11, Jessica Forcillo12, Francis D Ferdinand13, Gregory Fontana14, Piotr Suwalski15, Bob Kiaii16, Husam Balkhy17, Joerg Kempfert18, Anson Cheung19, Michael A Borger20, Michael Reardon21, Martin B Leon9, Jeffrey J Popma22, Niv Ad3,23. 1. 165591 Department of Cardiovascular Surgery, Marcus Heart and Vascular Center, Piedmont Heart and Vascular Institute, Atlanta, GA, USA. 2. 2720 Department of Cardiac Surgery, Fiona Stanley Hospital, University of Western Australia, Perth, Australia. 3. 12264 Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA. 4. Division of Adult Cardiothoracic Surgery, University of California, San Francisco, CA, USA. 5. 1878 Division of Cardiology, University of Colorado, Denver, CO, USA. 6. 384526 Department of Cardiology, Baylor Health Care System, Heart Hospital Baylor Plano, Dallas, TX, USA. 7. 2569 Department of Cardiology, Cleveland Clinic Foundation, Cleveland, OH, USA. 8. 5944 Department of Cardiovascular Surgery, Mount Sinai Health System, New York, NY, USA. 9. 5798 Division of Cardiology, Columbia University Medical Center, New York, NY, USA. 10. 1861 Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA. 11. 165591 Division of Cardiology, Marcus Heart and Vascular Center, Piedmont Heart Institute, Atlanta, GA, USA. 12. 5622 Department of Cardiac Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montréal, Canada. 13. 6595 Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine & UPMC Hamot Heart and Vascular Institute, University of Pittsburgh Medical Center, PA, USA. 14. Cardiovascular Institute, Los Robles Hospital and Medical Center, Thousand Oaks, CA, USA. 15. 359917 Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland. 16. 8789 Cardiothoracic Surgery, UC Davis Medical Center, Sacramento, CA, USA. 17. 12246 Section of Cardiac Surgery, University of Chicago Medicine, IL, USA. 18. Department of Cardiac Surgery, German Heart Institute, Berlin, Germany. 19. Department of Cardiac Surgery, The University of British Columbia, St. Paul's Hospital, Vancouver, Canada. 20. Department of Cardiac Surgery, Leipzig Heart Centre, Germany. 21. Department of Cardiac Surgery, Methodist DeBakey Heart & Vascular Center, Houston, TX, USA. 22. 1859 Department of Interventional Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA. 23. Cardiovascular Surgery, Adventist White Oak Medical Center, Silver Spring, MD, USA.
Abstract
OBJECTIVE: There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons. METHODS: Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year. RESULTS: Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios. CONCLUSIONS: In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.
OBJECTIVE: There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons. METHODS: Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year. RESULTS: Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I2 = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I2 = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios. CONCLUSIONS: In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.
Authors: William L Patrick; Zehang Chen; Jason J Han; Benjamin Smood; Akhil Rao; Fabliha Khurshan; Siddharth Yarlagadda; Amit Iyengar; John J Kelly; Joshua C Grimm; Marisa Cevasco; Joseph E Bavaria; Nimesh D Desai Journal: Cardiol Ther Date: 2022-03-31