Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis

European Society of Cardiology quality indicators for the care and outcomes of adults undergoing transcatheter aortic valve implantation

AIMS

To develop a suite of quality indicators (QIs) for the evaluation of the care and outcomes for adults undergoing transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

We followed the European Society of Cardiology (ESC) methodology for the development of QIs. Key domains were identified by constructing a conceptual framework for the delivery of TAVI care. A list of candidate QIs was developed by conducting a systematic review of the literature. A modified Delphi method was then used to select the final set of QIs. Finally, we mapped the QIs to the EuroHeart (European Unified Registries on Heart Care Evaluation and Randomized Trials) data standards for TAVI to ascertain the extent to which the EuroHeart TAVI registry captures information to calculate the QIs. We formed an international group of experts in quality improvement and TAVI, including representatives from the European Association of Percutaneous Cardiovascular Interventions, the European Association of Cardiovascular Imaging, and the Association of Cardiovascular Nursing and Allied Professions. In total, 27 QIs were selected across 8 domains of TAVI care, comprising 22 main (81%) and 5 secondary (19%) QIs. Of these, 19/27 (70%) are now being utilized in the EuroHeart TAVI registry.

CONCLUSION

We present the 2023 ESC QIs for TAVI, developed using a standard methodology and in collaboration with ESC Associations. The EuroHeart TAVI registry allows calculation of the majority of the QIs, which may be used for benchmarking care and quality improvement initiatives.

Rates, predictors, and causes of readmission after transcatheter aortic valve replacement in patients with chronic kidney disease

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a revolutionary procedure for severe aortic stenosis. The coexistence of chronic kidney disease (CKD) and TAVR introduces a challenge that significantly impacts patient outcomes.

AIM

To define readmission rates, predictors, and causes after TAVR procedure in CKD stage 1-4 patients.

METHODS

We used the national readmission database 2018 and 2020 to look into readmission rates, causes and predictors after TAVR procedure in patients with CKD stage 1-4.

RESULTS

Out of 24758 who underwent TAVR and had CKD, 7892 (32.4%) patients were readmitted within 90 days, and had higher adjusted odds of being females (adjusted odds ratio: 1.17, 95%CI: 1.02-1.31, P = 0.02) with longer length of hospital stay > 6 days, and more comorbidities including but not limited to diabetes mellitus, anemia, and congestive heart failure (CHF).

CONCLUSION

Most common causes of readmission included CHF (18.0%), sepsis, and complete atrioventricular block. Controlling readmission predictors with very close follow-up is warranted to prevent such high rate of readmission.

Non-femoral focused transaxillary access in TAVI: GARY data analysis and future trends

BACKGROUND

In patients not suitable for transfemoral transcatheter aortic valve implantation (TAVI), several access strategies can be chosen.

AIM

To evaluate the use and patient outcomes of transaxillary (TAx), transapical (TA), and transaortic (TAo) as alternative access for TAVI in Germany; to further evaluate surgical cutdown vs. percutaneous TAx access.

METHODS

All patients entered the German Aortic Valve Registry (GARY) between 2011 and 2019 who underwent non-transfemoral TAVI were included in this analysis. Patients with TA, TAo, or TAx TAVI were compared using a weighted propensity score model. Furthermore, a subgroup analysis was performed for TAx regarding the percutaneous or surgical cutdown approach.

RESULTS

Overall, 9686 patients received a non-transfemoral access. A total of 8918 patients (92.1%) underwent TA, 398 (4.1%) TAo, and 370 (3.8%) TAx approaches. Within the TAx subgroup, 141 patients (38.1%) received subclavian cutdown, while 200 (54.1%) underwent a percutaneous approach. The TA patients had a significantly lower 30-day survival than TAx patients (TA 90.92% vs. TAx 95.59%, p = 0.006; TAo 92.22% vs. TAx 95.59%, p = 0.102). Comparing percutaneous and cutdown TAx approaches, no significant differences were seen. However, more vascular complications occurred (TA 1.8%, TAo 2.4%, TAx 12.2%; p < .001), and the hospital length of stay was shorter (TA 12.9 days, TAo 14.1 days, TAx 12 days; p < .001) after TAx access.

CONCLUSION

It may be reasonable to consider TAx access first in patients not suitable for TF-TAVI, because the 30-day survival was higher compared with TA access and the 1-year survival was higher compared with TAo access. It remains important for the heart teams to offer alternative access modalities for patients not amenable to the standard TF-TAVI approaches.

Machine Learning-Based Predictive Model of Aortic Valve Replacement Modality Selection in Severe Aortic Stenosis Patients

The current recommendation for bioprosthetic valve replacement in severe aortic stenosis (AS) is either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). We evaluated the performance of a machine learning-based predictive model using existing periprocedural variables for valve replacement modality selection. We analyzed 415 patients in a retrospective longitudinal cohort of adult patients undergoing aortic valve replacement for aortic stenosis. A total of 72 clinical variables including demographic data, patient comorbidities, and preoperative investigation characteristics were collected on each patient. We fit models using LASSO (least absolute shrinkage and selection operator) and decision tree techniques. The accuracy of the prediction on confusion matrix was used to assess model performance. The most predictive independent variable for valve selection by LASSO regression was frailty score. Variables that predict SAVR consisted of low frailty score (value at or below 2) and complex coronary artery diseases (DVD/TVD). Variables that predicted TAVR consisted of high frailty score (at or greater than 6), history of coronary artery bypass surgery (CABG), calcified aorta, and chronic kidney disease (CKD). The LASSO-generated predictive model achieved 98% accuracy on valve replacement modality selection from testing data. The decision tree model consisted of fewer important parameters, namely frailty score, CKD, STS score, age, and history of PCI. The most predictive factor for valve replacement selection was frailty score. The predictive models using different statistical learning methods achieved an excellent concordance predictive accuracy rate of between 93% and 98%.

Bayesian interpretation of non-inferiority in transcatheter versus surgical aortic valve replacement trials: a systematic review and meta-analysis

OBJECTIVES

The concept of non-inferiority is widely adopted in randomized trials comparing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). However, uncertainty exists regarding the long-term outcomes of TAVR, and non-inferiority may be difficult to assess. We performed a systematic review and meta-analysis of randomized trials comparing TAVR and SAVR, with a specific emphasis on the non-inferiority margin for 5-year all-cause mortality.

METHODS

A systematic search was applied to 3 electronic databases. Randomized trials comparing TAVR and SAVR were included. Bayesian methods were implemented to evaluate the posterior probability of non-inferiority at different trial non-inferiority margins under either a vague, Cauchy, or a literature-based prior. Primary outcomes were 5-year actuarial all-cause mortality, and the probability of non-inferiority at various transformed trial non-inferiority margins. Secondary outcomes were long-term survival and 1- and 2-year actuarial survival.

RESULTS

Eight trials (n = 8698 patients) were included. Kaplan-Meier-derived 5-year survival was 61.6% (95% CI 59.8-63.5%) for TAVR, and 63.7% (95% CI 61.9-65.6%) for SAVR. Six trials (n = 6370 patients) reported all-cause mortality at 5-year follow-up. Under a vague prior, the posterior median relative risk for all-cause mortality of TAVR was 1.14, compared to SAVR (95% credible interval 1.06-1.22, probability of relative risk <1.00 = 0.01%, I2 = 0%). Similar results in terms of point estimate and uncertainty measures were obtained using frequentist methods. Based on the various trial non-inferiority margins, the results of the analysis suggest that non-inferiority at 5 years is no longer likely.

CONCLUSIONS

It is unlikely that TAVR is still non-inferior to SAVR at 5 years in terms of all-cause mortality.

Comparative Analysis of TAVR (Transcatheter Aortic Valve Replacement) and Surgical Valve Replacement for Low-Risk Patients

"Aortic stenosis" (AS) refers to a cardiac condition in which the aortic valve narrows, creating an obstruction that hinders the flow of blood from the left ventricle to the aorta. This contraction of the arteries influences normal blood circulation, leading to elevated pressure within the left ventricle and potentially culminating in heart failure. The management of AS typically involves two primary treatments, i.e. "surgical aortic valve replacement" (SAVR) and "transcatheter aortic valve replacement" (TAVR). In both cases, the goal is to replace a dysfunctional aortic valve with a functional substitute. Presently, TAVR has gained much preference over SAVR in clinical practice. However, there is a dearth of comprehensive research directly comparing the real-world outcomes of TAVR and SAVR. In recent years, TAVR has emerged as an attractive alternative to SAVR, yet studies that provide a detailed comparison of their real-world solutions are limited. This review article assesses the mortality of patients who underwent TAVR vis-a-vis patients who underwent SAVR.

Chronological comparison of TAVI and SAVR stratified to surgical risk: a systematic review, meta-analysis, and meta-regression

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has been established as a reasonable alternative to surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis. However, long-term outcomes including valve durability and the need for reintervention are unanswered, especially in younger patients who tend to be low surgical risk. We performed a meta-analysis comparing clinical outcomes after TAVI and SAVR over 5 years stratified to low, intermediate, and high surgical risks.

METHODS

We identified propensity score-matched observational studies and randomised controlled trials comparing TAVI and SAVR. Primary outcomes, including all-cause mortality, moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, pacemaker placement, and stroke, were extracted. Meta-analyses of outcomes after TAVI compared to SAVR were conducted for different periods of follow-up. Meta-regression was also performed to analyse the correlation of outcomes over time.

RESULTS

A total of 36 studies consisting of 7 RCTs and 29 propensity score-matched studies were selected. TAVI was associated with higher all-cause mortality at 4-5 years in patients with low or intermediate surgical risk. Meta-regression time demonstrated an increasing trend in the risk of all-cause mortality after TAVI compared with SAVR. TAVI was generally associated with a higher risk of moderate or severe aortic regurgitation, moderate or severe paravalvular regurgitation, and pacemaker placement.

CONCLUSIONS

TAVI demonstrated an increasing trend of all-cause mortality compared with SAVR when evaluated over a long-term follow-up. More long-term data from recent studies using newer-generation valves and state-of-the-art techniques are needed to accurately assign risks.

Patient Preferences for Long-Term Implant Care in Cochlear, Glaucoma and Cardiovascular Diseases

In the process of developing and implementing innovative implant technologies the consideration of patient preferences can be beneficial for patients, doctors and developers. Nevertheless, in existing literature, there is still scarce knowledge of patients' perspectives on long-term implant care. In this study, three discrete choice experiments (DCEs) were conducted in the context of cochlear implants (CI, n = 92), glaucoma implants (GI, n = 21) and cardiovascular implants (CVI, n = 23), examining the relative importance of attributes of long-term implant care from the patients' perspective. The participants chose between differently shaped options for implant-related care. The attributes of these care options were generated and selected based on previous literature reviews, group discussions and a diary study with patients. The choice data were analyzed via binary logit regression. In CI-DCE, the technological compatibility of the implant with newer implant models, accessories or devices from other manufacturers was highly valued by participants, whereas in GI-DCE the (in)dependency on glaucoma medication post-implantation had the greatest influence on participants' choice behavior. In CVI-DCE, the attribute with the highest relative importance related to the means of securing long-term treatment success. In all three DCE, shared decision making was relatively important for participants. Our results emphasized the importance of an adequate transfer of technological advancements in implant care for promoting patient benefits, such as the availability of comprehensible, understandable, high-quality information about current developments. Similarly, promoting technological health literacy and further pushing the technological compatibility, durability and safety of implants are directions for future implant development in accordance with patients' preferences. Therefore, the participation of implant wearers in the development process is encouraged.

Network Meta-Analysis Comparing Transcatheter, Minimally Invasive, and Conventional Surgical Aortic Valve Replacement

The landscape of aortic valve replacement (AVR) has evolved dramatically over the years, but time-varying outcomes have yet to be comprehensively explored. This study aimed to compare the all-cause mortality among 3 AVR techniques: transcatheter (TAVI), minimally invasive (MIAVR), and conventional AVR (CAVR). An electronic literature search was performed for randomized controlled trials (RCTs) comparing TAVI with CAVR and RCTs or propensity score-matched (PSM) studies comparing MIAVR with CAVR or MIAVR to TAVI. Individual patient data for all-cause mortality were derived from graphical reconstruction of Kaplan-Meier curves. Pairwise comparisons and network meta-analysis were conducted. Sensitivity analyses were performed in the TAVI arm for high risk and low/intermediate risk, as well as patients who underwent transfemoral (TF) TAVI. A total of 27 studies with 16,554 patients were included. In the pairwise comparisons, TAVI showed superior mortality to CAVR until 37.5 months, beyond which there was no significant difference. When restricted to TF TAVI versus CAVR, a consistent mortality benefit favoring TF TAVI was seen (shared frailty hazard ratio [HR] = 0.86, 95% confidence interval [CI] = 0.76 to 0.98, p = 0.024). In the network meta-analysis involving majority PSM data, MIAVR demonstrated significantly lower mortality than TAVI (HR = 0.70, 95% CI = 0.59 to 0.82) and CAVR (HR = 0.69, 95% CI = 0.59 to 0.80); this association remained compared with TF TAVI but with a lower extent of benefit (HR = 0.80, 95% CI = 0.65 to 0.99). In conclusion, the initial short- to medium-term mortality benefit for TAVI over CAVR was attenuated over the longer term. In the subset of patients who underwent TF TAVI, a consistent benefit was found. Among majority PSM data, MIAVR showed improved mortality compared with TAVI and CAVR but less than the TF TAVI subset, which requires validation by robust RCTs.

ESC/EACTS vs. ACC/AHA guidelines for the management of severe aortic stenosis

Aortic stenosis (AS) is a serious and complex condition, for which optimal management continues to evolve rapidly. An understanding of current clinical practice guidelines is critical to effective patient care and shared decision-making. This state of the art review of the 2021 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines and 2020 American College of Cardiology/American Heart Association Guidelines compares their recommendations for AS based on the evidence to date. The European and American guidelines were generally congruent with the exception of three key distinctions. First, the European guidelines recommend intervening at a left ventricular ejection fraction of 55%, compared with 60% over serial imaging by the American guidelines for asymptomatic patients. Second, the European guidelines recommend a threshold of ≥65 years for surgical bioprosthesis, whereas the American guidelines employ multiple age categories, providing latitude for patient factors and preferences. Third, the guidelines endorse different age cut-offs for transcatheter vs. surgical aortic valve replacement, despite limited evidence. This review also discusses trends indicating a decreasing proportion of mechanical valve replacements. Finally, the review identifies gaps in the literature for areas including transcatheter aortic valve implantation in asymptomatic patients, the appropriateness of Ross procedures, concomitant coronary revascularization with aortic valve replacement, and bicuspid AS. To summarize, this state of the art review compares the latest European and American guidelines on the management of AS to highlight three areas of divergence: timing of intervention, valve selection, and surgical vs. transcatheter aortic valve replacement criteria.

Biomechanics of Transcatheter Aortic Valve Implant

Transcatheter aortic valve implantation (TAVI) has grown exponentially within the cardiology and cardiac surgical spheres. It has now become a routine approach for treating aortic stenosis. Several concerns have been raised about TAVI in comparison to conventional surgical aortic valve replacement (SAVR). The primary concerns regard the longevity of the valves. Several factors have been identified which may predict poor outcomes following TAVI. To this end, the lesser-used finite element analysis (FEA) was used to quantify the properties of calcifications which affect TAVI valves. This method can also be used in conjunction with other integrated software to ascertain the functionality of these valves. Other imaging modalities such as multi-detector row computed tomography (MDCT) are now widely available, which can accurately size aortic valve annuli. This may help reduce the incidence of paravalvular leaks and regurgitation which may necessitate further intervention. Structural valve degeneration (SVD) remains a key factor, with varying results from current studies. The true incidence of SVD in TAVI compared to SAVR remains unclear due to the lack of long-term data. It is now widely accepted that both are part of the armamentarium and are not mutually exclusive. Decision making in terms of appropriate interventions should be undertaken via shared decision making involving heart teams.

Early outcomes of transcatheter versus surgical aortic valve implantation in patients with bicuspid aortic valve stenosis

BACKGROUND

Limited information is available on outcomes in patients with bicuspid aortic valve (BAV) stenosis undergoing transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR), as pivotal randomised trials excluded patients with BAV pathology due to anatomic complexity.

AIMS

The aim of the study was to compare early outcomes between TAVI and SAVR in patients with BAV stenosis.

METHODS

We queried the Nationwide Readmission Database (NRD) between 2016 and 2018 to identify adults who underwent TAVI or SAVR for BAV stenosis. The study's primary outcome was in-hospital mortality. Secondary outcomes were 30-day and six-month major adverse cardiovascular events (MACE). We matched both cohorts using propensity score matching, and applied logistic and Cox-proportional hazard regression to compute the odds ratio (OR), the hazard ratio (HR), and the 95% confidence interval (CI).

RESULTS

Out of 17,068 patients with BAV stenosis, 1,629 (9.5%) patients underwent TAVI and 15,439 (90.5%) underwent SAVR. After propensity score matching (PSM), we found 1,393 matched pairs. Of the matched pairs, 848 had complete six-month follow-ups. In the PSM cohort, TAVI was associated with reduced in-hospital mortality (0.7% vs 1.8%, OR: 0.35, 95% CI: 0.13-0.93; p=0.035), and a similar rate of MACE at 30 days (1% vs 1.5%, OR: 0.65, 95% CI: 0.27-1.58; p=0.343) and at six months (4.2% vs 4.9%, HR 0.86, 95% CI: 0.44-1.69; p=0.674), compared with SAVR.

CONCLUSIONS

In the propensity score-matched cohort, TAVI was associated with reduced odds of in-hospital mortality and a similar risk of 30-day and six-month MACE, supporting the feasibility of TAVI in BAV patients without a need for concurrent aortic root repair.

Fluid-Structure Interaction Analysis on the Influence of the Aortic Valve Stent Leaflet Structure in Hemodynamics

Transcatheter aortic valve replacement (TAVR) is a minimally invasive surgical treatment for heart valve disease. At present, personalized TAVR valves are not available for some patients. This study adopts the fluid-structure interaction (FSI) model of the research object that has a three-disc leaflet form and structural design in the valve leaflet area. The valve opening shape, orifice area, stress-strain, and distribution of hemodynamic flow and pressure were compared under the condition of equal contact area between valve and blood. The FSI method was used to simulate the complex three dimensional characteristics of the flow field more accurately around the valve after TAVR stent implantation. Three personalized stent systems were established to study the performance of the leaflet design based on computational fluid dynamics. By comparing the different leaflet geometries, the maximum stress on leaflets and stents of model B was relatively reduced, which effectively improved the reliability of the stent design. Such valve design also causes the opening area of the valve leaflet to increase and the low-velocity area of the flow field to decrease during the working process of the valve, thus reducing the possibility of thrombosis. These findings can underpin breakthroughs in product design, and provide important theoretical support and technical guidance for clinical research.

Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement. The aim of this study was to evaluate whether a relevant alteration in cerebral tissue oxygen saturation (rSO2) could be detected following TAVI. Retrospective data analysis included 275 patients undergoing TAVI between October 2016 and December 2020. Overall, rSO2 significantly increased following TAVI (64.6 ± 10% vs. 68.1 ± 10%, p < 0.01). However, a significant rise was only observed in patients with a preoperative rSO2 < 60%. Of the hemodynamic confounders studied, hemoglobin, mean arterial pressure and blood pH were lowered, while central venous pressure and arterial partial pressure of carbon dioxide (PaCO2) were slightly elevated (PaCO2: 39 (36−43) mmHg vs. 42 (37−47) mmHg, p = 0.03; pH: 7.41 (7.3−7.4) vs. 7.36 (7.3−7.4), p < 0.01). Multivariate linear regression modeling identified only hemoglobin as a predictor of altered rSO2. Patients with a EuroScore II above 4% and an extended ICU stay were found to have lower rSO2, while no difference was observed in patients with postoperative delirium or between the implanted valve types. Further prospective studies that eliminate differences in potential confounding variables are necessary to confirm the rise in rSO2. Future research should provide more information on the value of cerebral oximetry for identifying high-risk patients who will require further clinical interventions in the setting of the TAVI procedure.

Characterization of Turbulent Flow Behind a Transcatheter Aortic Valve in Different Implantation Positions

The development of turbulence after transcatheter aortic valve (TAV) implantation may have detrimental effects on the long-term performance and durability of the valves. The characterization of turbulent flow generated after TAV implantation can provide fundamental insights to enhance implantation techniques. A self-expandable TAV was tested in a pulse replicator and the three-dimensional flow field was extracted by means of tomographic particle image velocimetry. The valve was fixed inside a silicone phantom mimicking the aortic root and the flow field was studied for two different supra-annular axial positions at peak systole. Fluctuating velocities and turbulent kinetic energy were compared between the two implantations. Velocity spectra were derived at different spatial positions in the turbulent wakes to characterize the turbulent flow. The valve presented similar overall flow topology but approximately 8% higher turbulent intensity in the lower implantation. In this configuration, axial views of the valve revealed smaller opening area and more corrugated leaflets during systole, as well as more accentuated pinwheeling during diastole. The difference arose from a lower degree of expansion of the TAV's stent inside the aortic lumen. These results suggest that the degree of expansion of the TAV in-situ is related to the onset of turbulence and that a smaller and less regular opening area might introduce flow instabilities that could be detrimental for the long-term performance of the valve. The present study highlights how implantation mismatches may affect the structure and intensity of the turbulent flow in the aortic root.

Temporal Trend, Prevalence, Predictors, and Outcomes of Pericardial Diseases in Patients Undergoing Transcatheter Aortic Valve Repair

Background Pericardial disease (PD) - acute pericarditis (AP) and pericardial effusion (PE) - is a rare complication of transcatheter aortic valve repair (TAVR) although its prevalence, predictors, and outcomes are not well studied. Methods We used the National Inpatient Sample (NIS) database to find patients who received TAVR between 2011 and 2018. TAVR patients were divided into two groups: with and without PD (AP and/or PE). The baseline characteristics between the two groups were compared using the Chi-square test and student t-test. Variables with a p-value of 0.20 or less from the univariate logistic regression were included in the multivariate logistic regression to find independent predictors of PD in TAVR patients. Results Out of 218,340 TAVR hospitalizations, 4323 (1.2%) had a concurrent diagnosis of PD. TAVR patients with PD were older (81 ± 7 vs 80 ± 6 years, p < 0.05), more likely to be females (62 vs 46%, p < 0.001), white (84.2 vs 82.9%, p = 0.83), and had a higher burden of comorbidities (Table 3). TAVR patients with PD had higher in-hospital mortality rate (12.3 vs 1.9%, p < 0.001), mean length of stay (8.4 vs 5.3 days, p < 0.001), and mean total hospital cost ($283,389 vs $224,544, p < 0.001). Age > 75, female sex, atrial fibrillation (Afib), atrial flutter (Aflutter), peripheral vascular disease (PVD), coagulopathy, cirrhosis, malnutrition, percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), and pacemaker (PM) implantation were the independent predictors of PD in TAVR patients. Conclusion Older, white females with a higher burden of comorbidities and cardiovascular procedures are at higher risk of pericardial complications of TAVR procedure. Sex-based disparities in the prevalence of PD after TAVR is an area of further research. Careful selection of patients for TAVR is essential to reduce the burden of these complications.

Risk of Stroke After Transcatheter Aortic Valve Implantation: Epidemiology, Mechanism, and Management

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become an established and increasingly used approach for management of severe symptomatic aortic stenosis, showing similar or even superior outcomes compared with standard surgical aortic valve replacement (SAVR). Stroke after TAVI is a relatively rare, but serious complication, associated with potential prolonged disability and increased mortality.

AREAS OF UNCERTAINTY

The overall incidence of 30-day stroke in TAVI patients is 3%-4%, but varies between different trials. Initial data suggested a higher risk of stroke after TAVI when compared with SAVR. The association between subclinical leaflet thrombosis and cerebral embolism, presented as stroke, transient ischemic accident, or silent cerebral ischemia is not entirely elucidated yet. Moreover, TAVI for severe bicuspid aortic stenosis is a relatively new issue, bicuspid anatomy being initially excluded from the pivotal clinical trials investigating TAVI procedure. Efficient stroke prevention strategies are under investigation.

DATA SOURCES

In the present manuscript, we used the available published data from the most relevant clinical trials, registries, and meta-analysis of patients from different risk categories who underwent TAVI or SAVR.

THERAPEUTIC ADVANCES

Predictors of acute stroke are mainly procedure related. Technological development, improvements in bioprosthesis valve delivery catheters, and implantation technique may explain the decrease of stroke over the years since the beginning of TAVI procedures.

CONCLUSIONS

The overall evidences confirm similar or lower rate of stroke in TAVI versus SAVR. Risk predictors for acute stroke after TAVI are generally related to procedural factors, whereas late stroke is mainly associated with patient characteristics, with a variable impact on cognitive function. The optimal choice for the antithrombotic treatment in TAVI for stroke prevention is yet to be determined. Current data do not support routine use of cerebral embolic protection devices during TAVI.

Clinical practice guideline for transcatheter versus surgical valve replacement in patients with severe aortic stenosis in Latin America

In elderly (75 years or older) patients living in Latin America with severe symptomatic aortic stenosis candidates for transfemoral approach, the panel suggests the use of transcatheter aortic valve implant (TAVI) over surgical aortic valve replacement (SAVR). This is a conditional recommendation, based on moderate certainty in the evidence (⨁⨁⨁Ο).This recommendation does not apply to patients in which there is a standard of care, like TAVI for patients at very high risk for cardiac surgery or inoperable patients, or SAVR for non-elderly patients (eg, under 65 years old) at low risk for cardiac surgery. The suggested age threshold of 75 years old is based on judgement of limited available literature and should be used as a guide rather than a determinant threshold.The conditional nature of this recommendation means that the majority of patients in this situation would want a transfemoral TAVI over SAVR, but some may prefer SAVR. For clinicians, this means that they must be familiar with the evidence supporting this recommendation and help each patient to arrive at a management decision integrating a multidisciplinary team discussion (Heart Team), patient's values and preferences through shared decision-making, and available resources. Policymakers will require substantial debate and the involvement of various stakeholders to implement this recommendation.

MitraClip for mitral valve regurgitation and transcatheter aortic valve implantation for severe aortic valve stenosis: state-of-the-art

There is a worldwide expansion in percutaneous therapy for valvular heart disease. Rapidly evolving technology and the general increase in life expectancy will support the evolution of new treatment options dedicated to structural heart interventions. Transcatheter aortic valve implantation for severe aortic valve stenosis and percutaneous mitral valve repair with the MitraClip system for severe mitral regurgitation have been demonstrated as a feasible, innovative alternative for surgical treatment. Despite the inequality in clinical experience, both procedures have encouraging results and now are a part of everyday clinical practice. More importantly, rapid development is expected in the next decades. However, the global coronavirus disease 2019 (COVID-19) pandemic imposed redistribution of healthcare resources. Hospitals were obliged to modify their workflow and limit TAVI and MitraClip procedures to urgent or in highly symptomatic patients. Despite this encumbrance improvement in technology and experience supported by robust evidence from current studies might extend indications for both procedures. The future holds promise for this treatment modality to become the preferred procedure for all patients despite age or risk and reserving surgical treatment for a minority. Thus, we present state-of-the-art and current evidence for both methods assumed to change the paradigm of treatment of valvular heart failure in the future.

Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review

Aortic stenosis is a disease that is increasing in prevalence and manifests as decreased cardiac output, which if left untreated can result in heart failure and ultimately death. It is primarily a disease of the elderly who often have multiple comorbidities. The advent of transcatheter aortic valve therapies has changed the way we treat these conditions. However, long-term results of these therapies remain uncertain. Recently, there has been an increasing number of studies examining the role of both surgical aortic valve replacement and transcatheter aortic valve replacement. We therefore performed a systematic review using Ovid MEDLINE, Ovid Embase, and the Cochrane Library. Two investigators searched papers published between January 1, 2007, and to date using the following terms: "aortic valve stenosis," "aortic valve operation," and "transcatheter aortic valve therapy." Both strategies in aortic stenosis treatment highlighted specific indications alongside the pitfalls such as structural valve degeneration and valve thrombosis which have a bearing on clinical outcomes. We propose some recommendations to help clinicians in the decision-making process as technological improvements make both surgical and transcatheter therapies viable options for patients with aortic stenosis. Finally, we assess the role of finite element analysis in patient selection for aortic valve replacement. THVT and AVR-S are both useful tools in the armamentarium against aortic stenosis. The decision between the two treatment strategies should be best guided by a strong robust evidence base, ideally with a long-term follow-up. This is best performed by the heart team with the patient as the center of the discussion.

2020 update of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGHTG) on the position statement of the ÖKG and ÖGHTG for transcatheter aortic valve implantation 2011

This position statement is an update to the 2011 consensus statement of the Austrian Society of Cardiology (ÖKG) and the Austrian Society of Cardiac Surgery (ÖGTHG) for transfemoral transcatheter aortic valve implantation.Due to a number of recently published studies, broadening of indications and recommendations of medical societies and our own national developments, the ÖKG and the ÖGHTG wish to combine the 2017 ESC/EACTS guidelines for the management of valvular heart disease with a national position paper and to focus on certain details for the application in Austria. Thus, this position statement serves as a supplement and further interpretation of the international guidelines.

Patient values and preferences on valve replacement for aortic stenosis: a systematic review

The review aims to summarise evidence addressing patients’ values, preferences and practical issues on deciding between transcatheter aortic valve insertion (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. We searched databases and grey literature until June 2020. We included studies of adults with aortic stenosis eliciting values and preferences about treatment, excluding medical management or palliative care. Qualitative findings were synthesised using thematic analysis, and quantitative findings were narratively described. Evidence certainty was assessed using CERQual (Confidence in the Evidence from Reviews of Qualitative Research) and GRADE (Grading of Recommendations Assessment, Development and Evaluation). We included eight studies. Findings ranged from low to very low certainty. Most studies only addressed TAVI. Studies addressing both TAVI and SAVR reported on factors affecting patients’ decision-making along with treatment effectiveness, instead of trade-offs between procedures. Willingness to accept risk varied considerably. To improve their health status, participants were willing to accept higher mortality risk than current evidence suggests for either procedure. No study explicitly addressed valve reintervention, and one study reported variability in willingness to accept shorter duration of known effectiveness of TAVI compared with SAVR. The most common themes were desire for symptom relief and improved function. Participants preferred minimally invasive procedures with shorter hospital stay and recovery. The current body of evidence on patients’ values, preferences and practical issues related to aortic stenosis management is of suboptimal rigour and reports widely disparate results regarding patients’ perceptions. These findings emphasise the need for higher quality studies to inform clinical practice guidelines and the central importance of shared decision-making to individualise care fitted to each patient.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Multivariate meta-analysis model for the difference in restricted mean survival times

In randomized controlled trials (RCTs) with time-to-event outcomes, the difference in restricted mean survival times (RMSTD) offers an absolute measure of the treatment effect on the time scale. Computation of the RMSTD relies on the choice of a time horizon, $\tau$. In a meta-analysis, varying follow-up durations may lead to the exclusion of RCTs with follow-up shorter than $\tau$. We introduce an individual patient data multivariate meta-analysis model for RMSTD estimated at multiple time horizons. We derived the within-trial covariance for the RMSTD enabling the synthesis of all data by borrowing strength from multiple time points. In a simulation study covering 60 scenarios, we compared the statistical performance of the proposed method to that of two univariate meta-analysis models, based on available data at each time point and based on predictions from flexible parametric models. Our multivariate model yields smaller mean squared error over univariate methods at all time points. We illustrate the method with a meta-analysis of five RCTs comparing transcatheter aortic valve replacement (TAVR) with surgical replacement in patients with aortic stenosis. Over 12, 24, and 36 months of follow-up, those treated by TAVR live 0.28 [95% confidence interval (CI) 0.01 to 0.56], 0.46 (95% CI $-$0.08 to 1.01), and 0.79 (95% CI $-$0.43 to 2.02) months longer on average compared to those treated by surgery, respectively.

Impact of Interdisciplinary Outpatient Specialty Palliative Care on Survival and Quality of Life in Adults With Advanced Cancer: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

In advanced cancer, patients want to know how their care options may affect survival and quality of life, but the impact of outpatient specialty palliative care on these outcomes in cancer is uncertain.

PURPOSE

To estimate the impact of outpatient specialty palliative care programs on survival and quality of life in adults with advanced cancer.

METHODS

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of randomized controlled trials comparing outpatient specialty palliative care with usual care in adults with advanced cancer. Primary outcomes were 1 year survival and quality of life. Analyses were stratified to compare preliminary studies against higher-quality studies. Secondary outcomes were survival at other endpoints and physical and psychological quality-of-life measures.

RESULTS

From 2,307 records, we identified nine studies for review, including five high-quality studies. In the three high-quality studies with long-term survival data (n = 646), patients randomized to outpatient specialty palliative care had a 14% absolute increase in 1 year survival relative to controls (56% vs. 42%, p < .001). The survival advantage was also observed at 6, 9, 15, and 18 months, and median survival was 4.56 months longer (14.55 vs. 9.99 months). In the five high-quality studies with quality-of-life data (n = 1,398), outpatient specialty palliative care improved quality-of-life relative to controls (g = .18, p < .001), including for physical and psychological measures.

CONCLUSIONS

Patients with advanced cancer randomized to receive outpatient specialty palliative care lived longer and had better quality of life. Findings have implications for improving care in advanced cancer.

Reoperation After Transcatheter Aortic Valve Replacement: An Analysis of the Society of Thoracic Surgeons Database

OBJECTIVES

This study sought to report the largest series of patients receiving a surgical reoperation after transcatheter aortic valve replacement (TAVR) using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database.

BACKGROUND

TAVR has become an effective means of treating aortic stenosis. As TAVR is used in progressively lower-risk cohorts, management of device failure will become increasingly important.

METHODS

The STS Adult Cardiac Surgery Database was queried for patients with a history of prior TAVR undergoing surgical aortic valve replacement from 2011 to 2015. Observed-to-expected (O/E) mortality ratios were determined to facilitate comparison across reoperative indications and timing from index TAVR procedure.

RESULTS

A total of 123 patients met inclusion criteria (median age 77 years) with an STS Predicted Risk of Mortality of 4%, 4% to 8%, and >8% in 17%, 24%, and 59%, respectively. Median time to reoperation was 2.5 (interquartile range: 0.7 to 13.0) months, and the operative mortality rate was 17.1%. Common indications for reoperation included early TAVR device failures such as paravalvular leak (15%), structural prosthetic deterioration (11%), failed repair (11%), sizing or position issues (11%), and prosthetic valve endocarditis (10%). All pre-operative risk categories were associated with an increased O/E mortality ratio (Predicted Risk of Mortality <4%: O/E 5.5; 4% to 8%: O/E 1.7; >8%: O/E 1.2).

CONCLUSIONS

SAVR following early failure of TAVR, while rare, is associated with worse-than-expected outcomes as compared with similar patients initially undergoing SAVR. Continued experience with this developing technology is needed to reduce the incidence of early TAVR failure and further define optimal treatment of failed TAVR prostheses.

Renal Injury in All-Comers After Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

Background Acute kidney injury (AKI) following aortic valve replacement is associated with poor prognosis. Transcatheter aortic valve replacement (TAVR) is a novel strategy with a percutaneous approach and early recovery time. We conducted this meta-analysis to compare TAVR to surgical aortic valve replacement (SAVR) and their respective renal outcomes. Methods We searched for randomized controlled trials (RCTs) using MEDLINE, PUBMED, and Google Scholar databases from their inception till April 6, 2019, and included eight trials comparing TAVR to SAVR in cases that reported AKIs. Results We found a significant reduction in AKI after TAVR compared to SAVR at 30 days [n = 66 vs. n = 160, respectively; odds ratio (OR) = 0.38, 95% confidence interval (CI) = 0.28-0.51; p: <0.00001, I2 = 0%]. At one year, a trend towards reduced renal failure was noted in the TAVR arm compared to the SAVR arm (n = 74 vs. n = 129, respectively; OR = 0.57, 95% CI = 0.32-1.01; p = 0.05, I2 = 69%). Conclusion Based on our findings and analysis, we have concluded that TAVR is associated with significantly reduced renal injury at 30 days when compared to SAVR.

Comparing Transcatheter Aortic Valve Replacement (AVR) With Surgical AVR in Lower Risk Patients: A Comprehensive Meta-Analysis and Systematic Review

Background

Transcutaneous aortic valve replacement (TAVR) is a novel percutaneous procedure for severe aortic stenosis and has been recently approved by Food and Drug Administration in lower risk patients. We performed the first ever meta-analysis and literature review of clinical trials comparing both 30-day and 1-year outcomes in lower risk patients undergoing TAVR vs. surgical aortic valve replacement (SAVR, having Society of Thoracic Surgeons score < 4% or equivalent).

Methods

Using predefined selection criteria as above, 68 articles were identified. Seven eligible articles were selected after extensive review. Primary effect outcomes were 30-day and 1-year all-cause mortality using risk ratio (RR) with significant P value of < 0.05.

Results

A total of 4,859 subjects were included. Risk of 30-day all-cause mortality was 40.1% less in TAVR group, RR 0.59 (95% confidence interval (CI): 0.38 - 0.92, P = 0.02) with no significant heterogeneity. Six studies except Schymik et al also reported 1-year risk. This was, however, not statistically significant with a 21% decrease in the TAVR group, RR 0.79 (95% CI: 0.57 - 1.09, P = 0.15). Six studies reported 30-day risk of secondary outcomes. The risk of 30-day stroke was 36% less in TAVR group, although this was not statistically significant, RR 0.64 (95% CI: 0.38 - 1.9, P = 0.10). The risk of acute kidney injury (AKI) stage 2 and above was 56% less in post-TAVR patients, RR 0.43 (95% CI: 0.35 - 0.54, P < 0.001) with no heterogeneity. For vascular complications, RR was high in TAVR group 4.62 (95% CI: 1.42-15.18, P = 0.01). Significant heterogeneity was demonstrated though (I² = 81). The risks for permanent pacemaker (PPM) were also higher in the TAVR group, RR 3.30 (95% CI: 2.04 - 5.33, P < 0.001) and significant heterogeneity was observed. After removing Thyregod et al and Partner 3 trial from the analysis, heterogeneity was removed, but the RR was still high 3.21 (95% CI: 2.54 - 4.068, P < 0.001). Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. The 30-day risk for infective endocarditis was RR 0.67 (95% CI: 0.13 - 3.48, P = 0.63). The 1-year risk was similarly low but not significant, RR 0.73 (95% CI: 0.28 - 1.92, P = 0.53).

Conclusions

Among low risk patients, TAVR was found to be superior in short-term all-cause mortality and 1-year stroke, a result that was statistically significant for TAVR and close to significance for stroke. TAVR patients were also less likely to have post-operative bleeding and AKI stage 2 and beyond. Post-operative incidence of endocarditis among TAVR patients was low but not statistically significant. However, the rates of PPM and vascular complications are higher in TAVR patients. The results of TAVR in low risk population are thus extremely encouraging. However, the issue of long-term valve durability in this group needs further studies. Also, caution needs to be exercised while extending the indications to extremely young patients due to lack of enough studies.

Assessing the safety and efficacy of TAVR compared to SAVR in low-to-intermediate surgical risk patients with aortic valve stenosis: An overview of reviews

Background

Transcatheter aortic valve replacement (TAVR) was initially introduced to treat patients with aortic valve stenosis (AS) at high-risk for surgical aortic valve replacement (SAVR). Today, there is ample evidence supporting TAVR in high-risk groups. However, in recent years TAVR has been extended to low-to intermediate risk groups and relevant clinical evidence is still emerging, leaving some uncertainties.

Methods

To obtain information on TAVR versus SAVR in low-to intermediate risk groups, we conducted an overview of systematic reviews following PRISMA guidelines and based on a systematic search of EMBASE, MEDLINE, Cochrane and CRD databases. We focused on systematic reviews assessing mortality and VARC 2 as clinical outcomes.

Results

The majority of the 11 systematic reviews included in our study reported no differences in mortality between TAVR and SAVR at short and long-term follow-up times. Two reviews that included the most recent RCTs on low-risk patients reported a decreased mortality risk with TAVR at one-year follow-up. Regarding the secondary endpoints of stroke and MI, the majority of studies presented similar results for TAVR and SAVR. Acute Kidney Injury, Bleeding Complications, Atrial Fibrillation were less frequent with TAVR, with lower risk of Permanent Pacemaker Implantation and Aortic Regurgitation with SAVR.

Conclusions

Our overview indicated that TAVR is a promising intervention for low-to-intermediate surgical risk patients; however additional evidence from longer term follow-up is needed to confirm these findings. This overview highlights inconsistencies about reporting and presentation of data, most notably limited clarity on effects of risk of bias on trial results.

•

We reviewed the evidence for TAVR and SAVR in low-to intermediate risk patients.

•

Most reviews found no difference in mortality between TAVR and SAVR.

•

Acute Kidney Injury, Bleeding and Atrial Fibrillation were less frequent with TAVR.

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Pacemaker Implantation and Aortic Regurgitation were less frequent with SAVR.

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Most reviews found no difference for Stroke and Myocardial Infarction.

Clinical value of the 20% logistic EuroSCORE cut-off for selecting TAVI candidates: a single-centre cohort study analysis

Background

A logistic European System for Cardiac Operative Risk Evaluation (logEuroSCORE) ≥20% is frequently recognised as a finite criteria for transcatheter aortic valve implantation (TAVI) reimbursement, despite guideline modifications to reflect the appropriacy of TAVI in selected lower-risk patients. The aim was to evaluate the clinical value of this threshold cut-off in TAVI patients and to identify factors associated with mortality in those below this threshold.

Methods

We analysed data from a single-centre, German, observational, TAVI-patient registry, gathered between 2008 and 2016. Patients were stratified by logEuroSCORE (≥ or <20%) for comparisons. Logistic regression was performed to identify predictors of mortality at 1 year, with this analysis used to generate a calculated (‘real’) risk value for each patient.

Results

1679 patients (logEuroSCORE <20%: n=789; logEuroSCORE ≥20%: n=890) were included. LogEuroSCORE <20% patients were significantly younger (80.1 vs 81.6 years; p<0.001) and less comorbid than logEuroSCORE ≥20% patients, with a higher rate of transfemoral TAVI (35.6% vs 26.1%; p<0.001) and predilation (70.0% vs 63.3%; p=0.004). Patients with a logEuroSCORE <20% experienced more vascular complications (3.4% vs 1.5%; p=0.010). One-year survival was 88.3% in the logEuroSCORE <20% and 81.8% in the logEuroSCORE ≥20% group (p=0.005), with the calculated mortality risk falling within 2% of the logEuroSCORE in just 12.9% of patients. In the logEuroSCORE <20% group, only coronary artery disease was significantly predictive of 1-year mortality (OR 2.408; 95% CI 1.361 to 4.262; p=0.003).

Conclusions

At our institution, patients with a logEuroSCORE <20% selected for TAVI have excellent outcomes. The decision not to reimburse TAVI in such patients may be viewed as inappropriate.

Transcatheter Aortic Valve Implantation in Patients With Severe, Symptomatic Aortic Valve Stenosis at Intermediate Surgical Risk: A Health Technology Assessment

BACKGROUND

Surgical aortic valve replacement (SAVR) is the conventional treatment in patients at low or intermediate surgical risk. Transcatheter aortic valve implantation (TAVI) is a less invasive procedure, originally developed as an alternative for patients at high or prohibitive surgical risk.

METHODS

We conducted a health technology assessment of TAVI versus SAVR in patients with severe, symptomatic aortic valve stenosis at intermediate surgical risk, which included an evaluation of effectiveness, safety, cost-effectiveness, budget impact, and patient preferences and values. We performed a literature search to retrieve systematic reviews and selected one that was relevant to our research question. We complemented the systematic review with a literature search to identify randomized controlled trials published after the review. Applicable, previously published cost-effectiveness analyses were available, so we did not conduct a primary economic evaluation. We analyzed the net budget impact of publicly funding TAVI in people at intermediate surgical risk in Ontario. To contextualize the potential value of TAVI for people at intermediate surgical risk, we spoke with people who had aortic valve stenosis and their families.

RESULTS

We identified two randomized controlled trials; they found that in patients with severe, symptomatic aortic valve stenosis, TAVI was noninferior to SAVR with respect to the composite endpoint of all-cause mortality or disabling stroke within 2 years of follow-up (GRADE: High). However, compared with SAVR, TAVI had a higher risk of some complications and a lower risk of others. Device-related costs for TAVI (approximately $23,000) are much higher than for SAVR (approximately $6,000). Based on two published cost-effectiveness analyses conducted from the perspective of the Ontario Ministry of Health, TAVI was more expensive and, on average, more effective (i.e., it produced more quality-adjusted life-years) than SAVR. The incremental cost-effectiveness ratios showed that TAVI may be cost-effective, but the probability of TAVI being cost-effective versus SAVR was less than 60% at a willingness-to-pay value of $100,000 per quality-adjusted life-year. The net budget impact of publicly funding TAVI in Ontario would be about $2 million to $3 million each year for the next 5 years. This cost may be reduced if people receiving TAVI have a shorter hospital stay (≤ 3 days). We interviewed 13 people who had lived experience with aortic valve stenosis. People who had undergone TAVI reported reduced physical and psychological effects and a shorter recovery time. Patients and caregivers living in remote or northern regions reported lower out-of-pocket costs with TAVI because the length of hospital stay was reduced. People said that TAVI increased their quality of life in the short-term immediately after the procedure.

CONCLUSIONS

In people with severe, symptomatic aortic valve stenosis at intermediate surgical risk, TAVI was similar to SAVR with respect to the composite endpoint of all-cause mortality or disabling stroke. However, the two treatments had different patterns of complications. The study authors also noted that longer follow-up is needed to assess the durability of the TAVI valve. Compared with SAVR, TAVI may provide good value for money, but publicly funding TAVI in Ontario would result in additional costs over the next 5 years. People with aortic valve stenosis who had undergone TAVI appreciated its less invasive nature and reported a substantial reduction in physical and psychological effects after the procedure, improving their quality of life.

Meta-Analysis of Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Low Surgical Risk

Transcatheter aortic valve implantation (TAVI) is the current standard of care for patients with severe aortic stenosis who are at high risk for surgery. However, several recent studies have demonstrated the comparable safety and efficacy of TAVI in low-risk patients as well. We sought to pool the existing data to further assert its comparability. MEDLINE, Cochrane, and Embase databases were evaluated for relevant articles published from January 2005 to June 2019. Studies comparing outcomes of TAVI versus surgical aortic valve replacement in patients who are at low risk for surgery were included. Twelve studies (5 randomized controlled trials and 7 observational studies) totaling 27,956 patients were included. Follow-up ranged from 3 months to 5 years. Short-term all-cause mortality, short-term, and 1-year cardiac mortality were significantly lower in the TAVI group. One-year all-cause mortality, short-term, and 1-year stroke and myocardial infarction were similar in both groups. Rate of acute kidney injury and new-onset atrial fibrillation were lower in the TAVI group, whereas permanent pacemaker implantation and major vascular complications were higher in the TAVI group. Subgroup analysis of randomized controlled trials showed significantly lower 1-year all-cause mortality in the TAVI group. In conclusion, in severe aortic stenosis patients at low surgical risk, TAVI when compared with surgical aortic valve replacement, demonstrated a lower rate of short-term all-cause mortality, short-term, and 1-year cardiac mortality and similar in terms of 1-year all-cause mortality. TAVI is emerging as a safe and efficacious alternative for low surgical risk patients.

Aortic Stenosis: Guidelines and Evidence Gaps

Current guidelines for management of adults with aortic stenosis recommend aortic valve replacement for patients with clinical consequences due to hemodynamically severe valve obstruction. However, advances in surgical and transcatheter techniques, and improved valve design have led to decreased procedural risk and improved long-term outcomes. Transcatheter aortic valve replacement (TAVR) is recommended for patients with prohibitive surgical risk and is reasonable in intermediate and high-risk patients. Recent trials demonstrated favorable short-term outcomes in patients with low surgical risk undergoing TAVR compared with surgical AVR. We review the current Guidelines recommendations and highlight key controversies in management due to evidence gaps.

TAVR for aortic valve regurgitation: Ready for a randomized trial?

Transcatheter aortic valve replacement has been used successfully to treat native aortic valve regurgitation. Current observational evidence shows promising results in terms of procedural success while outcome data are difficult to interpret given the observational nature of the evidence. We are ready for a randomized trial, which will be very challenging to run.

Meta-Analysis Comparing Transcatheter Aortic Valve Implantation to Surgical Aortic Valve Replacement in Low Surgical Risk Patients

Transcatheter aortic valve implantation (TAVI) is recommended for inoperable and high risk surgical patients with severe aortic stenosis. It is noninferior to surgical aortic valve replacement (SAVR) in intermediate risk candidates. TAVI is currently being assessed for low surgical risk individuals. We performed a meta-analysis of randomized controlled trials (RCTs) and matched observational studies between TAVI and SAVR in low surgical risk patients. The primary outcomes were short-term and mid-term mortality and neurologic events. Secondary outcomes were other periprocedure complications. A total of 8 studies (3 RCTs and 5 matched observational studies) totaling 6,686 patients were included. No difference was seen in short-term mortality and neurologic events (risk ratio [RR] 0.68, 95% confidence interval [CI] 0.45 to 1.03, p 0.07 and RR 0.76, 95% CI 0.52 to 1.13, p 0.18) as well as mid-term mortality and neurologic events (RR 0.89, 95% CI 0.54 to 1.47, p 0.65 and RR 1.04, 95% CI 0.55 to 1.97, p 0.9) between the 2 groups. Reduced risk of new onset atrial fibrillation (RR 0.14, 95% CI 0.08 to 0.25, p <0.00001), acute kidney injury (RR 0.43, 95 CI 0.23 to 0.82, p 0.01), and bleeding (RR 0.43, 95% CI 0.27 to 0.69, p 0.0005) whereas increased risk of ≥ moderate aortic regurgitation (RR 6.53, 95% CI 3.48 to 12.24, p <0.00001), pacemaker or defibrillator implantation (RR 3.11, 95% CI 1.96 to 4.94, p <0.00001) and vascular complications (RR 5.29, 95% CI 1.58 to 17.70, p 0.007) was noted in TAVI arm. In conclusion, TAVI is comparable to SAVR in terms of short-term and mid-term mortality and neurologic events in low surgical risk patients. The risk of periprocedure events is variable.

Transcatheter aortic valve replacement versus surgery for symptomatic severe aortic stenosis: A reconstructed individual patient data meta-analysis

OBJECTIVES

We wished to undertake a reconstructed individual patient data meta-analysis of randomized clinical trials comparing transcatheter aortic valve replacement (TAVR) and surgery for patients with severe symptomatic aortic stenosis.

BACKGROUND

TAVR and surgery are both well-established methods for treating patients with symptomatic severe aortic stenosis who are at low, intermediate, and high risk for surgery.

METHODS

Data were identified by searches of Medline, Embase, CENTRAL and ClinicalTrials.gov for all randomized clinical trials, which compared TAVR and surgery that had published at least 1 year of follow-up. Individual patient data were reconstructed from Kaplan-Meier curves.

RESULTS

A total of 7,770 patients from seven randomized clinical trials were included in this meta-analysis. At 1 year, TAVR was associated with a lower risk of death from any cause (hazard ratio [HR], 0.85, 95% confidence interval [CI], 0.73-0.98; p = .03), disabling stroke (HR, 0.71; 95% CI, 0.54-0.93; p = .01) and the composite end point of death or disabling stroke (HR, 0.79; 95% CI, 0.67-0.92; p = .002). Significant interactions were found for access suitability, with TAVR associated with a lower risk of these end points in patients suitable for transfemoral access. TAVR was associated with a lower risk of periprocedural events, whereas the risk of late events was similar between TAVR and surgery.

CONCLUSIONS

At 1 year, TAVR was associated with a lower risk of death, disabling stroke and the composite end point, when compared with surgery. These associations were strongest within the subgroup of patients in whom transfemoral access was feasible.

Preoperative Anemia and Postoperative Mortality in Patients with Aortic Stenosis Treated with Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review and Meta-Analysis

BACKGROUND Patients with severe aortic stenosis who have comorbidities that prevent general anesthesia and open cardiothoracic surgery are candidates for transcatheter aortic valve implantation (TAVI). However, TAVI can result in patient mortality following the procedure. This systematic review of the literature and meta-analysis aimed to determine the relationship between preoperative anemia and postoperative mortality in patients following TAVI. MATERIAL AND METHODS PubMed, EMBASE, the Cochrane Library, and the Web of Science were systematically searched from their inception to February 2019 for relevant published studies that included patients with bicuspid aortic valve stenosis and tricuspid aortic valve stenosis who underwent TAVI and who had preoperative data on hemoglobin levels. The pooled odds ratios (OR) and 95% confidence interval (CI) were calculated using a random-effects generic inverse variance method. RESULTS Six published studies that involved 6,406 patients with aortic stenosis were included in the meta-analysis. There was no significant difference observed for the final pooled result for patients with and without anemia for the short-term 30-day postoperative mortality (OR, 1.34; 95% CI, 0.77-2.35). However, long-term mortality rates were significantly worse in patients with preoperative anemia compared with those without anemia (OR, 1.77; 95% CI, 1.34-2.35). CONCLUSIONS Systematic review of the literature and meta-analysis showed that pre-procedural anemia reduced long-term mortality following TAVI. This finding supports the need to correct preoperative anemia in patients with aortic stenosis to improve patient outcome following TAVI.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients at low and intermediate risk: A risk specific meta-analysis of randomized controlled trials

Background

Transcatheter aortic valve implantation (TAVI) is an option for treatment for patients with severe aortic stenosis who are at high risk for death with surgical aortic valve replacement (SAVR). It is unknown whether TAVI can be safely introduced to intermediate- and low-risk patients.

Objective

To compare the efficacy and safety of TAVI and SAVR in patients with intermediate- and low-surgical risk.

Data sources

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception to April 15, 2019.

Study selection

We included randomized controlled trials comparing TAVI with SAVR in patients with intermediate- and low-surgical risk.

Data extraction

Meta-analyses were conducted using random-effects models to calculate risk ratios (RR) with corresponding 95% confidence interval (CI). Two independent reviewers completed citation screening, data abstraction, and risk assessment. Primary outcome was a composite of all-cause mortality or disabling stroke at 12 months.

Data Synthesis

A total of 5 trials randomizing 6390 patients were included. In patients with low risk, TAVI was associated with a significant reduction in the composite of all-cause mortality or disabling stroke compared with SAVR (RR, 0.56; 95%CI, 0.40–0.79; I² = 0%). This benefit was not replicated in patients with intermediate risk (RR, 0.96; 95% CI, 0.80–1.15; I² = 0%). Similar results were seen separately in all-cause mortality and disabling stroke when TAVI was compared with SAVR.

Conclusion

For patients with severe aortic stenosis who were at low risk for death from surgery, TAVI achieved superior clinical outcomes compared to SAVR; however, these benefits were not seen in those with intermediate risk. This information may inform discussions about deciding between SAVR and TAVI for patients with low to intermediate risk separately.