Transcatheter versus surgical aortic valve replacement for severe aortic stenosis in low-risk adults: a network meta-analysis

Purpose To compare the safety and efficacy of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in low-risk severe aortic stenosis, and to assess the differential impact of balloon-expandable (BE) and self-expanding (SE) valve platforms on clinical outcomes. Methods A systematic search across seven databases was performed through May 2024. Frequentist and Bayesian network meta-analyses were conducted across three pre-specified time horizons: 30 days, 1 to 2 years, and 3 or more years. Results are reported as odds ratios (OR) with 95% confidence intervals (CI). Egger's regression testing and randomized controlled trial (RCT)-only sensitivity analyses were performed. Results Thirty-one studies (37,741 patients) were included. All TAVR types demonstrated comparable short-term and intermediate-term mortality to SAVR, with TAVR-BE ranking most favourably by Surface Under the Cumulative Ranking (SUCRA) (81.2% and 87.7%); these rankings should be interpreted alongside the non-significant effect estimates. In exploratory ≥3-year analyses (k=10 studies, consistent with RCT-only sensitivity analyses), TAVR-Mixed showed significantly higher mortality than SAVR (OR 1.963 [95% CI 1.620 to 2.378]; p<0.001), while TAVR-BE and TAVR-SE showed no significant difference. TAVR-BE significantly reduced 30-day rehospitalization (OR 0.625; p=0.007), stroke (OR 0.534; p=0.001), atrial fibrillation, acute kidney injury, and major bleeding versus SAVR. All TAVR platforms shortened hospital stay by approximately 4 days. SAVR was associated with significantly lower rates of paravalvular regurgitation and permanent pacemaker implantation at all time horizons. Conclusion In low-risk severe aortic stenosis, TAVR, particularly with balloon-expandable valves, appears to offer comparable short-term and intermediate-term survival with superior procedural safety versus SAVR. In exploratory ≥3-year analyses, SAVR was associated with lower mortality specifically within the heterogeneous TAVR-Mixed cohort; TAVR-BE and TAVR-SE showed no significant mortality difference from SAVR at this horizon, underscoring the importance of platform-specific and individualised decision-making.