Outcomes of transcatheter aortic valve implantation in young low-risk patients: a comprehensive meta-analysis of efficacy and safety

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Abstract Introduction Severe aortic stenosis (AS) was traditionally managed with surgical aortic valve replacement (SAVR). Transcatheter aortic valve implantation (TAVI) emerged as a less invasive alternative, originally for high-risk patients. Its use expanded to intermediate- and low-risk older patients based on promising results. This meta-analysis evaluates TAVI's outcomes in younger, low-risk patients, where SAVR is currently the gold standard. Methods Following PRISMA guidelines, we systematically searched randomized controlled trials (RCTs) comparing TAVI with SAVR in young (i.e. mean age <75 years) low-risk patients (i.e. STS score <4%) with severe symptomatic AS. The primary endpoint was a composite of death or disabling stroke. Secondary endpoints included all-cause mortality, disabling stroke, atrial fibrillation (AF), permanent pacemaker implantation (PPI), bleeding, functional class (NYHA), and quality of life (KCCQ score) improvements and prosthesis-related outcomes. Results Four RCTs were included with 4252 patients (2125 TAVI and 2127 SAVR). At a mean follow-up of 16±5 months, TAVI had a non-significantly lower incidence of death or disabling stroke (2.8% vs. 5.1% logRR 0.02 [0.00-0.04] p=0.11), and all-cause mortality (2.1% vs. 3.7%, logRR 0.01 [0.00-0.03] p=0.15). Disabling stroke was significantly lower in the TAVI group (0.9 vs. 2.1 logRR 0.01[0.00-0.02] p<0.01). Hospital readmission (7.1% vs. 9.5% logRR 0.03 [0.01-0.04] p<0.01), and bleeding rates (4.7% vs. 16%, logRR 0.14 [0.07-0.20] p<0.01) were significantly lower in the TAVI group. On the other hand, TAVI had a higher PPI rate (14% vs. 6%, logRR -0.08 [-0.13; -0.02], p<0,01) and significant paravalvular leak (2,5% vs. 0,5% logRR -0,02 95%CI [-0,04; -0,00] p<0,01 I2=77%). There were no statistically significant differences in the other prosthesis-related outcomes between both groups. Faster symptomatic and quality of life improvements were sustained in the TAVI group. Conclusion TAVI is a viable option for young low-risk patients with severe AS, being non-inferior to SAVR in all short-term outcomes. The benefits of TAVI include a lower risk of disabling strokes, reduced rates of readmission and bleeding, and faster-sustained improvements in symptoms and quality of life. The higher PPI and paravalvular leak rates in the TAVI group highlight the need for careful patient selection.

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