Original article
Adult cardiac
A Meta-Analysis of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement

https://doi.org/10.1016/j.athoracsur.2013.04.049Get rights and content

Background

Our preliminary meta-analysis suggests that transcatheter aortic valve implantation (TAVI) may not reduce the 30-day mortality rate over surgical aortic valve replacement (AVR) in high-risk patients with severe aortic stenosis (AS). We performed an updated formal meta-analysis of TAVI vs AVR for reduction not only of early but also of late all-cause mortality in AS.

Methods

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched through October 2012. Eligible studies were randomized controlled trials or adjusted observational comparative studies of TAVI vs AVR enrolling individuals with AS and reporting early (30-day or in-hospital) or late all-cause mortality, or both, as an outcome. Odds ratios or hazard ratios with 95% confidence intervals (adjusted odds ratios or hazard ratios in case of observational studies) were abstracted from each study.

Results

We identified two randomized trials and 15 adjusted observational studies enrolling 4,873 patients with severe AS. Pooled analysis suggested no significant difference in early (odds ratio, 0.92; 95% confidence interval, 0.70 to 1.19) and midterm (3-month to 3-year) total mortality (hazard ratio, 0.99; 95% confidence interval, 0.83 to 1.17) among patients assigned to TAVI vs AVR. Exclusion of any single study from the analysis did not substantively alter the overall result of our analysis. No evidence of significant publication bias was found.

Conclusions

Our meta-analysis of data of approximately 5,000 patients from 17 studies showed that TAVI is likely ineffective in reducing early and midterm all-cause mortality vs AVR in high-risk patients with AS.

Section snippets

Search Strategy

All randomized controlled trials and adjusted observational comparative studies of TAVI vs AVR enrolling patients with AS were identified using two-level search strategy. First, public-domain databases, including MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, were searched through October 2012 using Web-based search engines (PubMed and OVID). Keywords included percutaneous, transcatheter, transluminal, transarterial, transfemoral, transsubclavian, transaxillary,

Search Results

Our comprehensive search identified only two randomized controlled trials (Placement of Aortic Transcatheter Valves [PARTNER] 7, 8 and A Prospective, Randomised Trial of Transapical Transcatheter Aortic Valve Implantation vs Surgical Aortic Valve Replacement in Operable Elderly Patients With Aortic Stenosis [STACCATO] [9]) and 15 adjusted observational comparative studies 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 of TAVI vs AVR enrolling high-risk (∼10 to > 30 of EuroSCORE)

Early and Late Mortality Rates

It never would be surprising that early mortality rates after TAVI are compatible with those after AVR because observed TAVI mortality rates are similar to predicted AVR mortality rates not using the EuroSCORE but using the STS-PROM [3]. The EuroSCORE has been well known to overestimate the risks for AVR 26, 27, 28, 29; however, the STS-PROM is superior to the logistic EuroSCORE in predicting death in high-risk patients with severe AS [30]. Our previous pooled analysis [3] of 26 single-arm

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