Transcatheter versus Surgical Interventions for Severe Aortic Stenosis: A Contemporary Evaluation against Conservative Management

BackgroundAortic 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. ObjectivesThis 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. MethodsElectronic 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. ResultsThe 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. ConclusionsWhile 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.