Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis

Ahmed K Awad; Adham Ahmed; Dave M Mathew; Kathryn S Varghese; Serena M Mathew; Sofia Khaja; Paige C Newell; Alexis K Okoh; Sameer Hirji

doi:10.1016/j.jjcc.2023.08.010

Minimally invasive, surgical, and transcatheter aortic valve replacement: A network meta-analysis

J Cardiol. 2024 Mar;83(3):177-183. doi: 10.1016/j.jjcc.2023.08.010. Epub 2023 Aug 21.

Authors

Ahmed K Awad¹, Adham Ahmed², Dave M Mathew², Kathryn S Varghese², Serena M Mathew², Sofia Khaja², Paige C Newell³, Alexis K Okoh⁴, Sameer Hirji⁵

Affiliations

¹ Faculty of Medicine, Ain Shams University, Cairo, Egypt.
² City University of New York School of Medicine, New York, NY, USA.
³ Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
⁴ Emory University, Atlanta, GA, USA.
⁵ Division of Thoracic and Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. Electronic address: shirji@partners.org.

PMID: 37611742
DOI: 10.1016/j.jjcc.2023.08.010

Abstract

Background: Transcatheter aortic valve replacement (TAVR) has evolved as an alternative to surgical aortic valve replacement (SAVR). In addition to full-sternotomy (FS), recent reports have shown successful minimally-invasive SAVR approaches, including mini-sternotomy (MS) and mini-thoracotomy (MT). This network-meta-analysis (NMA) seeks to provide an outcomes comparison based on these different modalities (MS, MT, TAVR) compared with FS as a reference arm for the management of aortic valve disease.

Methods: A comprehensive literature search was performed to identify studies that compared minimally-invasive SAVR (MS/MT) to conventional FS-SAVR, and/or TAVR. Bayesian NMA was performed using the random effects model. Outcomes were pooled as risk ratios (RR) with their 95 % confidence intervals (CIs). Our primary outcomes included 30-day mortality, stroke, acute kidney injury (AKI), major bleeding, new permanent pacemaker (PPM), and paravalvular leak (PVL). We also assessed long-term mortality at the latest follow-up.

Results: A total of 27,117 patients (56 studies) were included; 10,397 patients had FS SAVR, 9523 had MS, 5487 had MT, and 1710 had TAVR. Compared to FS, MS was associated with statistically-significantly lower rates of 30-day mortality (RR, 0.76, 95%CI 0.59-0.98), stroke (RR, 0.84, 95%CI 0.72-0.97), AKI (RR, 0.76, 95%CI 0.61-0.94), and long-term mortality (RR 0.84, 95%CI 0.72-0.97) at a weighted mean follow-up duration of 10.4 years, while MT showed statistically-significantly higher rates of 30-day PVL (RR, 3.76, 95%CI 1.31-10.85) and major bleeding (RR 1.45; 95%CI 1.08-1.94). TAVR had statistically significant lower rates of 30-day AKI (RR 0.49, 95%CI 0.31-0.77), but showed statistically-significantly higher PPM (RR 2.50; 95%CI 1.60-3.91) and 30-day PVL (RR 12.85, 95%CI 5.05-32.68) compared to FS.

Conclusions: MS was protective against 30-day mortality, stroke, AKI, and long-term mortality compared to FS; TAVR showed higher rates of 30-day PVL and PPM but was protective against AKI. Conversely, MT showed higher rates of 30-day PVL and major bleeding. With the emergence of TAVR, the appropriate benchmarks for SAVR comparison in future trials should be the minimally-invasive SAVR approaches to provide clinical equipoise.

Keywords: Mini sternotomy; Mini thoracotomy; Minimally-invasive SAVR; SAVR; TAVR.

Publication types

Meta-Analysis

MeSH terms

Acute Kidney Injury* / epidemiology
Acute Kidney Injury* / etiology
Aortic Valve / surgery
Aortic Valve Stenosis* / surgery
Bayes Theorem
Heart Valve Prosthesis Implantation* / adverse effects
Hemorrhage
Humans
Network Meta-Analysis
Risk Factors
Stroke*
Transcatheter Aortic Valve Replacement* / adverse effects
Treatment Outcome