Awad AK, Ahmed A, Mathew DM, Varghese KS, Mathew SM, Khaja S, Newell PC, Okoh AK, Hirji S. Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis.
J Cardiol 2024;
83:177-183. [PMID:
37611742 DOI:
10.1016/j.jjcc.2023.08.010]
[Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND
Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease.
METHODS
A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up.
RESULTS
A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS.
CONCLUSIONS
MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.
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