Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis

Hiroki Ueyama; Toshiki Kuno; Matthew Harrington; Hisato Takagi; Parasuram Krishnamoorthy; Samin K Sharma; Annapoorna Kini; Stamatios Lerakis

doi:10.1016/j.jcin.2021.04.038

Impact of Surgical and Transcatheter Aortic Valve Replacement in Low-Gradient Aortic Stenosis: A Meta-Analysis

JACC Cardiovasc Interv. 2021 Jul 12;14(13):1481-1492. doi: 10.1016/j.jcin.2021.04.038. Epub 2021 May 3.

Authors

Hiroki Ueyama¹, Toshiki Kuno², Matthew Harrington², Hisato Takagi³, Parasuram Krishnamoorthy⁴, Samin K Sharma⁴, Annapoorna Kini⁴, Stamatios Lerakis⁵

Affiliations

¹ Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA; Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA.
² Department of Medicine, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, New York, USA.
³ Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan.
⁴ Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA.
⁵ Division of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York, USA. Electronic address: stamatios.lerakis@mountsinai.org.

PMID: 33939605
DOI: 10.1016/j.jcin.2021.04.038

Abstract

Objectives: The aim of this study was to assess the impact of aortic valve replacement (AVR) on survival in patients with each subclass of low-gradient (LG) aortic stenosis (AS) and to compare outcomes following surgical AVR (SAVR) and transcatheter AVR (TAVR).

Background: LG severe AS encompasses a wide variety of pathophysiology, including classical low-flow, LG (LF-LG), paradoxical LF-LG, and normal-flow, LG (NF-LG) AS, and uncertainty exists regarding the impact of AVR on each subclass of LG AS.

Methods: PubMed and Embase were queried through October 2020 to identify studies comparing survival with different management strategies (SAVR, TAVR, and conservative) in patients with LG AS. Pairwise meta-analysis comparing AVR versus conservative management and network meta-analysis comparing SAVR versus TAVR versus conservative management were performed.

Results: Thirty-two studies with a total of 6,515 patients and a median follow-up time of 24.2 months (interquartile range: 36.5 months) were included. AVR was associated with a significant decrease in all-cause mortality in classical LF-LG (hazard ratio [HR]: 0.42; 95% confidence interval [CI]: 0.36 to 0.48), paradoxical LF-LG (HR: 0.41; 95% CI: 0.29 to 0.57), and NF-LG (HR: 0.41; 95% CI: 0.27 to 0.62) AS compared with conservative management. SAVR and TAVR were each associated with a decrease in all-cause mortality in classical LF-LG (HR: 0.46 [95% CI: 0.38 to 0.55] and 0.49 [95% CI: 0.37 to 0.64], respectively), paradoxical LF-LG (HR: 0.42 [95% CI: 0.28 to 0.65] and 0.42 [95% CI: 0.25 to 0.72], respectively), and NF-LG (HR: 0.40 [95% CI: 0.21 to 0.77] and 0.46 [95% CI: 0.26 to 0.84], respectively) AS compared with conservative management. No significant difference was observed between SAVR and TAVR.

Conclusions: In all subclasses of LG AS, AVR was associated with a significant decrease in all-cause mortality regardless of surgical or transcatheter approach.

Keywords: aortic valve replacement; low-gradient aortic stenosis; transcatheter aortic valve replacement.

Publication types

Meta-Analysis
Research Support, Non-U.S. Gov't

MeSH terms

Aortic Valve / diagnostic imaging
Aortic Valve / surgery
Aortic Valve Stenosis* / diagnostic imaging
Aortic Valve Stenosis* / surgery
Heart Valve Prosthesis Implantation*
Humans
Risk Factors
Severity of Illness Index
Stroke Volume
Transcatheter Aortic Valve Replacement*
Treatment Outcome