Benefits and limitations of transcatheter vs. surgical aortic valve replacements

Author(s): Jaspreet Kaur, Alexander Bykersma

Background: Surgical Aortic Valve Replacement (SAVR) is the gold standard treatment for severe aortic stenosis. However, advanced age and interfering comorbidities combined with increased perioperative risks often make patients poor surgical candidates, necessitating the rise of the less invasive transcatheter aortic valve replacement (TAVR) approach. With the emergence of new evidence, we reviewed the literature comparing the benefits and harms of TAVR and SAVR in patients of varying surgical risk.

Methods: A literature search of English-language articles published from January 2009 through June 2020 was designed in Ovid MEDLINE, PubMed, up-to-date, and Scopus. We used the following search headings in different combinations: aortic stenosis; aortic valve replacement; transcatheter aortic valve replacement; TAVR; SAVR; surgical valve replacement; high risk; intermediate risk; and low risk.

Results: In meta-analysis, TAVR is better or non-inferior to SAVR in inoperable, high-risk, and intermediate patients when comparing mortality, rehospitalisation, severe disablement, and symptom control. These results remained consistent during follow-up at 1 year and 5 years. Evidence comparing TAVR and SAVR in low risk patients is limited, however emerging seminal trials show TAVR to have lower rates of deaths from any cause and rehospitalisation after 1 year (8.5% vs. 15.1%). In all cohorts, TAVR has significantly lower risk of major bleeding but increase risk of major vascular events, paravalvular leaks, and pacemaker implantation compared to SAVR.

Conclusion: TAVR has successfully provided a minimally invasive alternative for patients with significant operative and perioperative risks associated with surgical replacement. While it is a superior treatment option than SAVR in high and intermediate risk patients, the final choice remains an individual one. Further research is required in low risk cohorts, though emerging evidence indicate a likely favourable outcome for TAVR.