Transcatheter versus surgical aortic valve replacement in moderate and high-risk patients: a meta-analysis.

Objectives: The evidence of the benefits of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for patients of high or intermediate surgical risk is not consistent. We performed a meta-analysis to compare major adverse outcomes after TAVR or SAVR. Methods: We searched propensity score matched studies or randomized clinical trials comparing the risks of mortality, stroke, major bleeding, acute renal injury, pacemaker implantation, vascular complications and prostheses haemodynamic performance between TAVR and SAVR in patients with moderate or high risk. Combined odds ratios (ORs), relative risk or mean differences with corresponding 95% confidence intervals (CIs) were calculated using a random effects model. Analyses of sensitivity and publication bias were also conducted. Results: We included 5 clinical trials and 37 observational studies, enrolling 20 224 patients (TAVR, n = 9099 and SAVR, n = 11 125). The pooled analysis suggested no differences in early (OR = 1.11, 95% CI 0.9-1.39, P = 0.355) or late mortality (relative risk = 0.91, 95% CI 0.78-1.05, P = 0.194). TAVR was associated with a lower risk of major bleeding (OR = 0.42, 95% CI 0.25-0.69, P < 0.001) and acute kidney injury (OR = 0.51, 95% CI 0.34-0.71) but with an increase in the incidence of pacemaker implantation (OR = 2.31, 95% CI 1.73-3.08) and vascular complications (OR = 4.88, 95% CI 2.84-8.39). Residual aortic regurgitation was more frequent after TAVR (OR= 6.83, 95% CI 4.87-9.6). SAVR prostheses were associated with poor trans-prosthetic gradients (mean difference: -2.4 mmHg, 95% CI - 3.27 to - 1.53). Conclusions: TAVR and SAVR have similar short and long-term all-cause mortality and risk of stroke among patients of moderate or high surgical risk. TAVR decreases the risk of major bleeding, acute kidney injury and improves haemodynamic performance compared with SAVR but increases the risk of vascular complications, the need for a pacemaker and residual aortic regurgitation.

Multiple procedures for coronary disease: a surgeon's perspective from the operating theatre.

To illustrate the interplay between coronary surgery and percutaneous interventions in secondary revascularisation, we report on the case of a patient with a long-standing history of ischaemic coronary disease, who underwent multiple percutaneous coronary interventions (PCI) and two coronary artery bypass grafting (CABG) procedures. The course of action selected for treatment was based on the anatomical features of the coronary lesions and the patient's clinical situation.