Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement in Low-Risk Patients: A Propensity Score Matched Analysis

Background: Since the introduction of transcatheter aortic valve implantation (TAVI) in 2002 as alternative to surgical aortic valve replacement (SAVR), benefits of TAVI were shown for high- and intermediate-risk surgical patients although industry-independent trials substantiating findings of landmark studies are lacking. However, currently, TAVI and SAVR for low-risk patients are compared in several trials. We herein aimed to determine differences in outcomes of SAVR and TAVI in surgical low-risk patients.

Methods: Between 2008 and 2016, 2,549 patients received TAVI and 1,506 received isolated SAVR at our institution. For comparison, all TAVI/SAVR patients with a log EuroSCORE II ˂4% and transfemoral (TF) approach were included. Exclusion comprised non-TF, concomitant procedures, non-CE mark devices, cases of aortic regurgitation, re-do (valve-in-valve), stentless bioprostheses, and endocarditis leading to 437 TAVI and 234 SAVR patients. After propensity score matching, cohorts presented no significant intergroup differences in baseline parameters (TAVI n = 114/SAVR n = 114). Outcomes were evaluated in accordance to VARC-2 criteria.

Results: The 30-day outcomes presented no significant differences regarding death (TAVI 2/114 vs. SAVR 2/114, p = 1.0), stroke (3/114 vs. 3/114, p = 1.0), acute kidney injury (8/114 vs. 3/114, p = 0.35), or permanent pacemaker implantation (PPM) (16.8 vs. 8.5%, p = 0.12). Length of ICU stay was 2.3 ± 3.3 vs. 2.4 ± 2.8 days (p = 0.73) and length of hospital stay 9.7 ± 8.9 vs. 7.2 ± 5.6 days (p = 0.01). Hemodynamic outcomes revealed comparable valve performance regarding postprocedural transvalvular pressure gradients (pmax: 21.0 vs. 20.0 mm Hg, p = 0.8; pmean: 10.0 vs. 11.0 mm Hg, p = 0.7) but more significant paravalvular leakage (PVL) in the TAVI group (PVL ≥2: 7.7 vs. 0.9%, p = 0.02; PVL grade 1: 40.8 vs. 4.6%; p ˂ 0.001). Kaplan–Meier survival analysis presented similar 1- and 5-year survival for TAVI and SAVR.

Conclusion: In this analysis, TAVI presented comparable outcomes to SAVR in surgical low-risk patients. Remaining drawbacks of TAVI are higher rates of PPM implantation and significant PVL. Survival analysis showed similar long-term outcomes in the matched patient cohorts. Although statistically not significant, drawback of TAVI in 5-year survival may be founded in hidden confounders in terms of patient selection. These findings will have to be confirmed in larger prospective trials.