Comparison of transcatheter aortic valve implantation with other approaches to treat aortic valve stenosis: a systematic review and meta-analysis

Gernot Wagner,Henrike Arfsten,Sabine Steiner,Harald Mayr,Brigitte Wildner,Gerald Gartlehner,Deddo Moertl

doi:10.1186/s13643-019-0954-3

Abstract

BackgroundTranscatheter aortic valve replacement (TAVI) is an alternative treatment for patients with symptomatic severe aortic stenosis ineligible for surgical aortic valve replacement (SAVR) or at increased perioperative risk. Due to continually emerging evidence, we performed a systematic review and meta-analysis comparing benefits and harms of TAVI, SAVR, medical therapy, and balloon aortic valvuloplasty.MethodsWe searched MEDLINE, Embase, and Cochrane CENTRAL from 2002 to June 6, 2017. We dually screened abstracts and full-text articles for randomized controlled trials (RCTs) and propensity score-matched observational studies. Two investigators independently rated the risk of bias of included studies and determined the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). If data permitted, we performed meta-analyses using random- and fixed-effects models.ResultsOut of 7755 citations, we included six RCTs (5862 patients) and 13 observational studies (6376 patients). In meta-analyses, patients treated with SAVR or TAVI had similar risks for mortality at 30 days (relative risk [RR] 1.05; 95% confidence interval [CI] 0.82 to 1.33) and 1 year (RR 1.02; 95% CI 0.93 to 1.13). TAVI had significantly lower risks for major bleeding but increased risks for major vascular complications, moderate or severe paravalvular aortic regurgitation, and new pacemaker implantation compared to SAVR. Comparing TAVI to medical therapy, mortality did not differ at 30 days but was significantly reduced at 1 year (RR 0.51; 95% CI 0.34 to 0.77).ConclusionsGiven similar mortality risks but different patterns of adverse events, the choice between TAVI and SAVR remains an individual one.

Highlights

Transcatheter aortic valve replacement (TAVI) is an alternative treatment for patients with symptomatic severe aortic stenosis ineligible for surgical aortic valve replacement (SAVR) or at increased perioperative risk
One million elderly patients in the European countries and 540,000 in North America suffer from symptomatic severe aortic stenosis
We included 13 observational propensity score-matched studies (6376 patients), of those 12 studies compared Transcatheter aortic valve implantation (TAVI) with SAVR [22,23,24,25,26,27,28,29,30,31,32,33] and one TAVI with medical therapy/balloon aortic valvuloplasty (BAV) [34]

Summary

Introduction

Transcatheter aortic valve replacement (TAVI) is an alternative treatment for patients with symptomatic severe aortic stenosis ineligible for surgical aortic valve replacement (SAVR) or at increased perioperative risk. One million elderly patients in the European countries and 540,000 in North America suffer from symptomatic severe aortic stenosis These numbers are expected to increase due to demographic changes [1]. Surgical aortic valve replacement (SAVR) has been the only recommended treatment of choice in patients with symptomatic severe AS, transcatheter aortic valve replacement (TAVI) has emerged as an alternative treatment option over the last 15 years [3]. The European Society of Cardiology (ESC) guidelines recommend TAVI in patients with severe symptomatic AS who are considered inoperable [3]. These recommendations are mainly based on one randomized controlled trial (RCT), the Placement of Aortic (2019) 8:44

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Conclusion