Transcatheter versus Surgical Interventions for Severe Aortic Stenosis: A Contemporary Evaluation against Conservative Management
Document Type
Article
Abstract
Background: Aortic valve replacement (AVR), through transcatheter (TAVR) or surgical (SAVR) means, serves as a pivotal therapeutic approach for severe aortic stenosis (AS). While both modalities show advantages over conservative management, the long-term mortality benefits post-AVR, especially when comparing TAVR with SAVR, remain uncertain.
Objectives: This study aimed to perform an in-depth meta-analysis of randomized controlled trials (RCT) comparing TAVR versus SAVR, as well as their outcomes against conservative management.
Methods: Electronic databases were searched up to December 7, 2023. Individual patient data extracted from Kaplan-Meier plots, underwent pooling and modeling with stratification by surgical risk. The primary endpoint was all-cause mortality at 5 years.
Results: The study included eleven RCTs and twelve non-RCTs, encompassing 4215 patients undergoing TAVR, 4017 undergoing SAVR and comparing 11,285 AVR patients with 23,358 receiving conservative management. TAVR exhibited significantly lower all-cause mortality at 6 months (HR 0.62, 95% CI: 0.52-0.74) compared to SAVR, with no significant difference beyond 6 months (HR 1.08, 95% CI: 0.98-1.19). Additionally, over a 5-year period, there were no significant disparities in cardiovascular mortality (HR 0.98, 95% CI: 0.83-1.16) or stroke (HR 1.02, 95% CI: 0.75-1.38) between TAVR and SAVR, while TAVR exhibited a notable advantage with a markedly reduced risk of cardiovascular mortality in the initial 6 months (HR 0.64, 95% CI: 0.46-0.87) and stroke within the first month post-procedure (HR 0.31, 95% CI: 0.19-0.51). Furthermore, the mean aortic valve area and pressure gradient remained comparable between TAVR and SAVR, exhibiting stability throughout the 5-year follow-up period. AVR markedly reduced all-cause mortality compared to medical therapy (P < 0.001), with 5-year crude mortality rates of 31.6% versus 49.3%, and a difference in restricted mean survival time of 8.9 months. Similar outcomes were observed across high, intermediate, and low surgical risk categories.
Conclusions: While TAVR demonstrated early mortality reduction compared to SAVR, no distinctions emerged in the overall 5-year follow-up, regardless of surgical risk. AVR notably improved survival over conservative therapy. This study advocates for the preference of TAVR or SAVR in severe AS patients when feasible.
DOI
10.1101/2024.04.14.24305770
Publication Date
4-15-2024
Recommended Citation
Ma Z, Shadman S, Maddahi Y, Krishnamurthy M, Puleo P, Shirani J. Transcatheter versus Surgical Interventions for Severe Aortic Stenosis: A Contemporary Evaluation against Conservative Management. medRxiv. 2024 Apr 15:2024-04.