Transcatheter aortic valve implantation

Comparative Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement in Moderate-Risk Patients With Aortic Stenosis: A Systematic Review of Clinical Trials

Aortic stenosis (AS) is a prevalent condition among the elderly, characterized by the narrowing of the aortic valve, which, if untreated, can lead to heart failure and decreased quality of life in terms of reduced activity and high mortality in one to two years. Surgical aortic valve replacement (SAVR) has long been the standard treatment for AS. However, it poses significant risks, particularly in older patients with comorbidities. In recent years, transcatheter aortic valve replacement (TAVR) has emerged as a less invasive alternative and is increasingly used in low- and moderate-risk patients. This review seeks to assess the comparative outcomes of TAVR and SAVR in patients with moderate-risk AS. A systematic review was conducted in accordance with PRISMA guidelines, focusing on randomized controlled trials (RCTs) that compared TAVR and SAVR in this patient population. Also, the review included three major RCTs: PARTNER 2, UK TAVI, and DEDICATE. We analyzed the key outcomes of TAVR and SAVR, such as mortality, reintervention rates, complications (such as myocardial infarction, prosthetic valve endocarditis, and pacemaker implantation), and reintervention rates, to evaluate the relative efficacy and safety of TAVR and SAVR. The analysis included data from 4,359 patients across the three trials. TAVR demonstrated a lower all-cause mortality in two of the three trials, with an overall trend favoring TAVR in terms of survival. However, TAVR was associated with a higher incidence of prosthetic valve endocarditis, a greater need for pacemaker implantation, and more frequent reinterventions compared to SAVR. In conclusion, the findings suggest that TAVR may be a better option for moderate-risk AS patients, offering higher survival rates and a less invasive recovery process. While TAVR carries increased risks of endocarditis and pacemaker dependency, its overall benefits, particularly in terms of lower mortality and improved patient outcomes, make it a preferable option over SAVR for many patients. However, acknowledging potential limitations such as variations in trial design and differences in patient populations would indeed provide a more comprehensive perspective. Further research and long-term follow-up are essential to confirm these findings and refine patient selection criteria.

Recent advances in aortic valve replacement

Aortic valve replacement has stood the test of time but is no longer an operation that is exclusively approached through a median sternotomy using only sutured prostheses. Currently, surgical aortic valve replacement can be performed through a number of minimally invasive approaches employing conventional mechanical or bioprostheses as well as sutureless valves. In either case, the direct surgical access allows inspection of the valve, complete excision of the diseased leaflets, and debridement of the annulus in a controlled and thorough manner under visual control. It can be employed to treat aortic valve pathologies of all natures and aetiologies. When compared with transcatheter valves in patients with a high or intermediate preoperative predictive risk, conventional surgery has not been shown to be inferior to transcatheter valve implants. As our understanding of sutureless valves and their applicability to minimally invasive surgery advances, the invasiveness and trauma of surgery can be reduced and outcomes can improve. This warrants further comparative trials comparing sutureless and transcatheter valves.

Recent advances in aortic valve replacement for aortic stenosis

Aortic valve replacement is no longer an operation that is approached solely through a median sternotomy. Recent advances in the fields of transcatheter valves have expanded the proportion of patients eligible for intervention. Comparisons between transcatheter valves and conventional surgery have shown non-inferiority of transcatheter valve implants in patients with a high or intermediate pre-operative predictive risk. With advances in our understanding of sutureless valves and their applicability to minimally invasive surgery, the invasiveness and trauma of surgery can be reduced with potential improvements in outcome. The strategy of care has radically changed over the last decade.