Meta-Analysis of Transcatheter Versus Surgical Aortic Valve Replacement in Low Surgical Risk Patients: An Update

Transcatheter aortic valve replacement (TAVR) is increasingly considered as an alternative to surgical aortic valve replacement (SAVR) for low-risk patients with aortic stenosis. However, its long-term efficacy remains uncertain. To compare clinical outcomes and procedural complications of TAVR versus SAVR in low-risk patients with aortic stenosis. We updated our 2019 systematic review by searching MEDLINE, EMBASE, and Cochrane Central (May 2019-April 2025) for randomized controlled trials (RCTs) comparing TAVR and SAVR in low-risk patients with aortic stenosis. We extracted outcomes at 30 days, 12 months, and ≥5 year follow-up. Risk ratios (RRs) and 95% confidence intervals (CIs) were estimated using random-effects models. Risk of bias was assessed using the Cochrane Risk of Bias (RoB) 2 tool. Five RCTs (n = 4,532) were included. TAVR reduced 30-day all-cause mortality (RR: 0.45, 95% CI: 0.37-0.55), cardiovascular mortality (RR: 0.45, 95% CI: 0.38-0.54), atrial fibrillation (RR: 0.21, 95% CI: 0.10-0.41), and life-threatening bleeding (RR: 0.28, 95% CI: 0.13-0.58), but increased pacemaker implantation (RR: 3.10, 95% CI: 1.23-7.82). Mortality benefits persisted at 12 months. At ≥5 years, results were inconclusive due to wide CIs across outcomes, including all-cause death (RR: 0.99, 95% CI: 0.72-1.35), cardiovascular death (RR: 0.93, 95% CI: 0.64-1.35), atrial fibrillation (RR: 0.44, 95% CI: 0.16-1.22), endocarditis (RR: 0.70, 95% CI: 0.33-1.45) and aortic reintervention (RR: 1.21, 95% CI: 0.59-2.49). TAVR shows early clinical benefits in low-risk patients with aortic stenosis, but long-term outcomes compared to SAVR remain uncertain. Individualized heart team decision-making remains essential.