Longer-term and landmark analysis of transcatheter vs. surgical aortic-valve implantation in severe aortic stenosis: a meta-analysis.

Summary

Across 8 randomized trials (n=8,749), TAVI showed favorable early outcomes (≤30 days) but a higher risk beyond 2 years versus SAVR, especially among higher-risk patients and with balloon-expandable valves; no long-term disadvantage was seen with self-expanding valves. Temporal patterns and valve-type interactions inform patient selection and device choice.

Key Findings

• Higher 5-year composite (death/disabling stroke) for TAVI vs SAVR in higher-risk patients (OR 1.25, 95% CI 1.07–1.47); no difference in lower-risk
• Valve-type interaction: balloon-expandable TAVI higher long-term risk (OR 1.38), self-expanding TAVI no difference (OR 1.03)
• Landmark: ≤30 days TAVI favorable (OR 0.76), 30 days–2 years comparable (OR 1.04), >2 years TAVI higher risk (OR 1.36)

Clinical Implications

For higher-risk patients and balloon-expandable valves, expect potential long-term disadvantages after year 2; closer surveillance and individualized selection are warranted. Self-expanding valves may attenuate long-term risk differences.

Limitations

• Device iterations and procedural expertise evolved across trial eras, contributing to heterogeneity
• Meta-analysis relies on study-level data; unmeasured confounding in subgroup/device comparisons possible

Future Directions

Patient-level meta-analyses and contemporary trials with next-generation valves are needed to confirm temporal patterns and refine selection strategies, including durability and reintervention endpoints.