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The following is a summary of “Transcatheter vs Surgical Aortic Valve Replacement in Lower-Risk Patients: An Updated Meta-Analysis of Randomized Controlled Trials,” published in the March 2025 issue of the Journal of the American College of Cardiology by Reddy et al. 

Long-term clinical outcomes are particularly relevant for lower-risk patients with severe aortic stenosis undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). As additional randomized trials have emerged, an updated analysis is warranted to refine clinical decision-making in this expanding patient population. This study presents a systematic review and meta-analysis, incorporating conventional pairwise comparisons and pooled survival analyses using reconstructed time-to-event individual participant data (IPD) from all available randomized evidence comparing long-term outcomes between TAVR and SAVR in lower-risk patients. The prespecified primary endpoint was all-cause mortality, with key secondary endpoints including stroke and the composite of death or disabling stroke. 

Advanced statistical modeling, including Cox proportional hazards frailty regression and restricted mean survival time models, was applied to reconstructed time-to-event IPD, supplemented by sensitivity analyses utilizing proportional odds models with frailty terms. Conventional pairwise meta-analyses were performed under both random and fixed effects assumptions. A total of six randomized trials enrolling 5,341 lower-risk patients were included, with 2,717 patients assigned to TAVR and 2,624 to SAVR, with a weighted mean follow-up duration of 35.7 months. At five years, pooled survival analyses demonstrated a significant 20% reduction in the hazard of all-cause mortality in the TAVR group compared with SAVR (HR: 0.80; 95% CI: 0.66-0.97; P = 0.02). Similarly, TAVR was associated with a 19% lower hazard of all-cause death or disabling stroke (HR: 0.81; 95% CI: 0.68-0.96; P = 0.01). No significant difference was observed in stroke rates between the two interventions (HR: 0.97; 95% CI: 0.74-1.26; P = 0.80). These findings suggest that in lower-risk patients, TAVR provides a survival advantage and a lower risk of death or disabling stroke compared with SAVR, while stroke rates remain comparable. However, given that the majority of patients have not yet reached five-year follow-up, these results should be interpreted with caution, as longer-term data may further refine the risk-benefit profile of TAVR in this population. 

As the utilization of TAVR continues to expand, additional randomized trials and extended follow-up are necessary, particularly in younger patients, to assess valve durability, the feasibility of future reinterventions, and long-term clinical outcomes. These findings provide important insights for clinicians and patients considering valve replacement strategies in the lower-risk population, reinforcing the need for individualized treatment approaches based on evolving evidence.

Source: sciencedirect.com/science/article/abs/pii/S0735109725001317