Red Light for TAVR in Low Surgical Risk Patients

A new study raises an alarm against expanding transcatheter aortic valve replacement (TAVR) procedures to low surgical risk patients, since 2 year mortality seems higher in these patients with TAVR, compared to conventional surgery. This study will soon be published in Catheter Cardiovasc Interv.

Expanding TAVR to low risk patients might involve risks we have not yet properly assessed, so we should prioritize surgery as plan A until conclusive evidence is provided. 

Read also: Is Emergency Cardiac Surgery Necessary in TAVR?

This meta-analysis included 6 studies published between 2012 and 2017, including a total 3484 patients. Short term mortality resulted identical, but soon curves started to part and, for two year mortality, the difference in favor of surgery reached significant values (TAVI 17.2%  vs surgery 12.7%; p=0.006).

Even though study outcomes are provoking, we should bear in mind there are limitations common to all registries and that there might be confounders beyond our control.

The meta-analysis supports present guideline recommendations and, until further information from the three ongoing randomized studies (PARTNER 3, Medtronic Transcatheter Aortic Valve Replacement in Low Risk Patients, and NOTION 2) we should stay cautious and stick to surgery when it comes to low surgical risk patients. All studies follow up patients for over 2 years, and together they pool up 3500 subjects, so the correct answer only requires patience.

Read also: Coronary Disease Works as a 30-Day Predictor in TAVR.

The meta-analysis has also found the cost benefit ratio for periprocedural complications in low surgical risk patients is similar to that of the general TAVR population, with lower kidney failure and bleeding than surgery, but with more pacemaker implantation and vascular complications.

Conclusion

In low surgical risk, severe aortic stenosis patients, TAVR showed higher mid-term mortality than surgery. Until further data is provided, surgery should be the standard course of action for this population.

Original title: Transcatheter versus surgical aortic valve replacement in patients at low surgical risk: a meta-analysis of randomized trials and propensity score matched observational studies.

Reference: Witberg G et al. Catheter Cardiovasc Interv. 2018;Epub ahead of print.

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