Transcatheter Versus Surgical Aortic Valve Replacement in Severe Aortic Stenosis With Reduced Left Ventricular Ejection Fraction (≤50%): A Systematic Review and Meta-Analysis of Hemodynamic and Clinical Outcomes

Severe aortic stenosis with reduced left ventricular ejection fraction (LVEF) represents a clinically vulnerable subgroup in whom the comparative benefits and risks of transcatheter aortic valve replacement/implantation (TAVR/TAVI) and surgical aortic valve replacement (SAVR) remain incompletely defined. This systematic review and meta-analysis compared early clinical outcomes and one-year hemodynamic and ventricular recovery outcomes between TAVR/TAVI and SAVR in adults with severe native aortic stenosis and baseline LVEF ≤50% or an extractable reduced-LVEF subgroup. Searches were performed in PubMed/MEDLINE, Scopus, Web of Science, Embase, and SciELO on February 27, 2026, with an updated search on April 1, 2026. Embase was used with awareness that it incorporates ClinicalTrials.gov records, and supplementary registry searches and verification included ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform, and the EU Clinical Trials Register. The protocol was prospectively registered in PROSPERO (International Prospective Register of Systematic Reviews) (CRD420261348568). Risk of bias was assessed using RoB 2 (revised Cochrane risk-of-bias tool for randomized trials) for randomized evidence and ROBINS-I (Risk Of Bias In Non-randomized Studies of Interventions) V2 for nonrandomized comparative studies; certainty of evidence was evaluated using GRADE (Grading of Recommendations Assessment, Development and Evaluation). Seven comparative studies met eligibility criteria, including randomized subgroup analyses and matched or adjusted observational cohorts; six contributed to at least one pooled quantitative synthesis. Thirty-day all-cause mortality did not show a statistically significant difference between TAVR/TAVI and SAVR (RR 0.85, 95% CI 0.46-1.57; 6 studies; n=1,651). TAVR/TAVI was associated with a lower risk of early stroke (RR 0.48, 95% CI 0.25-0.91; 4 studies; n=1,285). Permanent pacemaker implantation was numerically more frequent after TAVR/TAVI, but the estimate was highly imprecise (RR 2.66, 95% CI 0.49-14.38; 3 studies; n=1,082). At one year, the pooled estimates did not establish a clear difference in mean transprosthetic gradient (MD -1.70 mmHg, 95% CI -11.22 to 7.82; 3 studies; n=654) or LVEF recovery (MD 2.91 percentage points, 95% CI -6.20 to 12.01; 3 studies; n=615). In severe aortic stenosis with reduced LVEF, TAVR/TAVI may reduce early stroke, and short-term mortality appears broadly similar to SAVR; however, evidence for pacemaker implantation, one-year gradients, and LVEF recovery remains very uncertain and should not be interpreted as evidence of equivalence between strategies.