1. Trans- catheter aortic valve replacement vs
Trans- catheter aortic valve replacement vs. surgical aortic valve replacement in patients at intermediate-high risk:
A meta- analysis
M. Carnero Alcázar, M. Gª Bouza, B. Ramchandani,
J. Cobiella, A. Alswies, F.Reguillo, L. Maroto.
Madrid, Spain.

2. No Conflicts Of Interest

3. Background J Am Coll Cardiol. 2014;63:2438-88
Eur J Cardiothorac Surg Oct;42(4):S1-44.

4. Background

5. Objectives
To perform a meta-analysis to compare major adverse outcomes after TAVR or SAVR
Primary events
Secondary events
Death *
Major Stroke *
Pacemaker Implantation *
Acute Kidney Injury *
Major or Life- Threatening Bleeding *
Vascular Complications *
Moderate or Severe Residual Aortic Regurgitation*
Mean Trans-prosthetic Gradients *

6. Methods
2009- June 2016
Propensity score matched studies or clinical trials comparing TAVR and SAVR
STS score above 4% or logistic EuroSCORE above  10% in both arms of treatment
At least, 20 patients per arm
Differences of STS score <1% score or EuroSCORE <5% between arms
One of the following events
Early events (30 days post procedure or in-hospital): mortality, major stroke, major or life-threatening bleeding, vascular complications, acute kidney injury or pacemaker implantation
Late events (follow-up > 12 months): mortality or major stroke
Haemodynamic findings: mean transprosthetic gradients or more than mild residual aortic regurgitation (RAR).

7. Methods
Inverse variance-weighted averages of logarithmic ORs and RRs and mean of the gradients differences in random-effects models
Heterogeneity was analysed by means of I2 (25% was mild, 50% moderate and 75% high) and Q test (p<0.10 was consistent with significant heterogeneity).
Sensitivity analyses were performed
Forest plots were used to illustrate the pooled estimates.
Terms: ("sutureless" or "SAVR" or "surgical aortic valve replacement" or “SuAVR”) and (“TAVI” or “TAVR” or "transcatheter aortic valve replacement" or “transcatheter aortic valve implantation” or "trans- catheter aortic valve replacement" or “trans- catheter aortic valve implantation” or "transfemoral aortic valve replacement" or "transfemoral aortic valve implantation" or “trans- femoral aortic valve replacement” or “trans- femoral aortic valve implantation” or "transapical aortic valve implantation” or "transapical aortic valve replacement” or “trans- apical aortic valve implantation“ or “trans- apical aortic valve replacement” or “trans- aortic valve implantation” or “transaortic valve implantation” or “trans- aortic valve replacement” or “transaortic valve replacement” or “trans- subclavian aortic valve replacement” or “trans- subclavian aortic valve implantation” or “transsubclavian aortic valve replacement” or “transsubclavian aortic valve implantation”)

8. Results n=

9. Results OR 1.11 (0.89-1.39) Early Mortality RCT OR 0.8 (0.58-1.11) PSM
n= 5 (3838), I2 = 0%
OR 0.8 ( )
Early Mortality
PSM
n= 35 (15766), I2 = 0%
OR 1.19 ( )
OVERALL
n= 40 (19 694), I2 = 0%
OR 1.11 ( )

10. Results OR 0.91 (0.78-1.05) Late Mortality RCT OR 0.93 (0.84-1.04) PSM
n= 4 (3757), I2 = 0%
OR 0.93 ( )
Late Mortality
PSM
n= 13 (6368), I2 = 0%
OR 0.91 ( )
OVERALL
n= 17 (10 125), I2 = 0%
OR 0.91 ( )

11. Results OR 0.97 (0.75-1.25) Early Stroke RCT OR 1.01 (0.65-1.56) PSM
n= 5 (3828), I2 = 0%
OR 1.01 ( )
PSM
Early Stroke
n= 26 (13352), I2 = 0%
OR 0.96 ( )
OVERALL
n= 31 (17180), I2 = 0%
OR 0.97 ( )

12. Results OR 0.78 (0.56-1.07) Late Stroke RCT OR 1.01 (0.65-1.56) PSM
n= 4 (3827), I2 = 0%
OR 1.01 ( )
PSM
Late Stroke
n= 6 (4469), I2 = 0%
OR 0.66 ( )
OVERALL
n= 10 (8226), I2 = 0%
OR 0.78 ( )

13. Vascular Complications Mean Difference Mean Gradient (mmHg)
Major or LT Bleeding
n=21 (11 073)
OR 0.42 ( )
Results
n=19 (9 643)
OR 0.51 ( )
AKI
n=28 (14 655)
OR 2.31 ( )
Pacemaker
Vascular Complications
n=17 (12 570)
OR 4.88 ( )
Moderate or Severe RAR
n=22 (9 290)
OR 6.83 ( )
Mean Difference Mean Gradient (mmHg)
n=17 (8 630)
MD -2.4 (-3.27—-1.5)

14. Results x OR RR OR RR OR OR OR OR OR MD Favors TAVR Favors SAVR
Subgroup
Early Mortality
Late Mortality
Early Stroke
Late Stroke
Major Bleeding
AKI PM
Vas Compl.
RAR
Mean Difference
RCT
PSM studies
Inter Risk
High Risk
SuAVR
Antegrade
Retrograde
Balloon Expandable
Expandable x OR
(95% CI) RR
(95% CI) OR
(95% CI) RR
(95% CI) OR
(95% CI) OR
(95% CI) OR
(95% CI) OR
(95% CI) OR
(95% CI) MD
(95% CI)
Favors TAVR
Favors SAVR

15. Conclusions Among patients with moderate or high surgical risk…
TAVR and SAVR have similar short and long-term all-cause mortality and risk of stroke.
TAVR is superior to SAVR for major bleeding, acute kidney injury and hemodynamic performance.
SAVR reduces the risk of vascular complications, need for pacemaker and residual aortic regurgitation.
These conclusions remain mostly unchanged in subgroup analysis.
Limitations
Some major events were not analyzed (AFib, endocarditis…)
Limited data on durability of prostheses…
3. Comparison of RAR might be inaccurate as the assessment of RAR is highly dependent on the observer.

16. HEART TEAM

18. Results

19. Background

20. Results Early Mortality Early Stroke Late Mortality Late Stroke
n= 40 (19 694)
Early Mortality
Early Stroke
RR 0.91 ( )
n= 17 (8 093)
OR 0.97 ( )
n= 31 (15 375)
Late Mortality
Late Stroke
n= 10 (8 093)
RR 0.78 ( )