Surgical versus transcatheter treatment of aortic valve stenosis—a meta-analysis of low-risk randomized trials with completed 5-year follow-up

OBJECTIVES: Transcatheter aortic valve implantation (TAVI) has shown similar short-term outcomes when compared to surgical aortic valve replacement (SAVR) in randomized controlled trials (RCTs). Longer-term outcomes for low-risk cohorts are now emerging. Here, we analyse all low-risk TAVI versus SAVR RCTs that completed 5-year follow-up. METHODS: A systematic MEDLINE database search was conducted through 6 May 2025, identifying all low-risk RCTs comparing TAVI with SAVR that had completed 5-year follow-up. The primary outcomes were all-cause mortality and the composite of all-cause mortality or disabling stroke. Secondary outcomes included stroke, cardiovascular death, aortic reintervention, myocardial infarction, paravalvular leak, need for permanent pacemaker and postprocedural atrial fibrillation. RESULTS: Four RCTs, including 3557 patients (TAVI: 1829; SAVR: 1728), were analysed. There was no difference between cohorts in all-cause mortality incidence rate ratio (IRR) 1.01, 95% confidence interval (CI): 0.88-1.16, P = 0.88 or the composite of all-cause mortality or disabling stroke (IRR 1.03, 95% CI: 0.92-1.17, P = 0.59). TAVI was associated with increased risk of mild or greater paravalvular leak (IRR 7.63, 95% CI: 2.82-20.65, P < 0.001) and permanent pacemaker implantation (IRR 2.12, 95% CI: 1.5-2.98, P < 0.001) and a decreased risk of postprocedural atrial fibrillation (IRR 0.44, 95% CI: 0.28-0.71, P < 0.001). CONCLUSIONS: In published RCTs of low-risk cohorts with completed 5-year follow-up, there was no significant difference between TAVI and SAVR neither in overall mortality nor in the composite of mortality and stroke. Valve-related events (paravalvular leaks and pacemaker need) were higher with TAVI, while atrial fibrillation was more common with SAVR.