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The following is a summary of “Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients at lower surgical risk: meta-analysis of randomized trials,” published in the March 2025 issue of the Canadian Journal of Cardiology by Lerman et al.

Transcatheter aortic valve implantation (TAVI) has emerged as a viable alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis, with its use expanding to patients across the entire spectrum of surgical risk. This meta-analysis aimed to compare the safety and efficacy of TAVI and SAVR in patients with lower risk, defined as those with a mean or median Society of Thoracic Surgeons (STS) score below 4. Researchers conducted a comprehensive analysis of randomized controlled trials (RCTs) evaluating clinical outcomes between these two interventions, incorporating both point-estimate meta-analysis and reconstructed individual patient data (RIPD) survival analysis. 

The primary endpoints included all-cause mortality, stroke, and a composite of all-cause mortality or disabling stroke. A systematic review identified six eligible RCTs, comprising 2,668 patients who underwent TAVI and 2,573 who underwent SAVR, with a mean follow-up duration of 3.02 years. Their findings demonstrated that TAVI was associated with a significantly lower risk of all-cause mortality ([RR] 0.68, 95% [CI] 0.52–0.88) and a reduced incidence of the composite endpoint of all-cause mortality or disabling stroke (RR 0.69, 95% CI 0.55–0.86), with no significant difference in stroke risk up to two years post-procedure. However, longer-term point-estimate analyses suggested no significant differences in mortality or stroke between the two treatment strategies. RIPD survival analysis revealed that the mortality benefit of TAVI was primarily driven by an early survival advantage, with restricted mean survival time (RMST) differences of less than 2.5 months for the primary endpoints and less than one month for all-cause mortality. 

Furthermore, TAVI was associated with a lower risk of major bleeding, acute kidney injury, and new-onset atrial fibrillation compared with SAVR, although it conferred an increased risk of permanent pacemaker implantation and moderate-to-severe aortic regurgitation. These findings suggest that in patients with lower surgical risk, TAVI offers improved early survival and reduced procedural complications compared with SAVR, though the long-term durability and clinical impact of TAVI require further investigation. While the short-term benefits of TAVI are evident, continued research and extended follow-up data from ongoing trials are essential to fully elucidate its long-term safety and efficacy relative to SAVR in this patient population.

Source: onlinecjc.ca/article/S0828-282X(25)00183-7/abstract