RESUMO
BACKGROUND: To compare safety and efficacy of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients at low-intermediate risk, given the paucity of robust data. METHODS: We performed an aggregate data meta-analysis of 7 randomized controlled trials (RCTs) and 6,778 patients comparing TAVR with SAVR for aortic stenosis (AS) in low-intermediate risk patients (Society of Thoracic Surgeons risk-score ≤8%) using the random-effects model. Primary outcome was all-cause mortality at 30-day, 1-year and 2-year of follow-up. Secondary outcomes included cardiac-mortality, stroke, acute kidney injury (AKI), atrial fibrillation (AF), permanent pacemaker (PPM) implantation, major-bleeding, moderate-severe paravalvular regurgitation (PVR) and rehospitalization. RESULTS: All-cause mortality, cardiac-mortality and stroke were comparable between the two groups. AF was higher with SAVR at 30-day [odds ratio (OR) 0.17, 95% confidence intervals (CI): 0.12-0.24] thorough to 2-year (OR 0.34, 95% CI: 0.21-0.55), while PPM implantation was higher with TAVR (30-day: OR 3.31, 95% CI: 1.64-6.66, 2-year: OR 3.17, 95% CI: 1.02-9.86). Moderate-severe PVR was more prevalent with TAVR at all follow-ups. On inter-group comparison, patients in the low-risk group had an even lower risk of AF, but a higher risk of PPM implantation as compared to the patients in the intermediate-risk group undergoing TAVR. CONCLUSIONS: Compared to SAVR, TAVR had comparable all-cause mortality and stroke, lower-risk of AF, but was associated with a higher risk of PPM implantation and moderate-severe PVR in low-intermediate-risk patients. Thus, highlighting the need for longer-term follow-up before robust inferences are drawn.
RESUMO
BACKGROUND: Older adults (≥70-year-old) are under-represented in the published data pertaining to unprotected left main coronary artery disease (ULMCAD). HYPOTHESIS: Percutaneous coronary intervention (PCI) might be comparable to coronary artery bypass grafting (CABG) for revascularization of ULMCAD. METHODS: We compared PCI versus CABG in older adults with ULMCAD with an aggregate data meta-analyses (4880 patients) of clinical outcomes [all-cause mortality, myocardial infarction (MI), repeat revascularization, stroke and major adverse cardiac and cerebrovascular events(MACCE)] at 30 days, 12-24 months & ≥36 months in patients with mean age ≥70 years and ULMCAD. A meta-regression analysis evaluated the effect of age on mortality after PCI. Odds ratios (OR) and 95% confidence intervals (CI) were estimated using random-effects model. RESULTS: All-cause mortality between PCI and CABG was comparable at 30-days (OR0.77, 95% CI 0.42- 1.41) and 12-24-months (OR 1.22, 95% CI 0.78-1.93). PCI was associated with a markedly lower rate of stroke at 30-day follow-up in octogenarians (OR 0.14, 95% CI 0.02-0.76) but an overall higher rate of repeat revascularization. At ≥36-months, MACCE (OR 1.26,95% CI 0.99-1.60) and all-cause mortality (OR 1.39, 95% CI 1.00-1.93) showed a trend favoring CABG but did not reach statistical significance. On meta-regression, PCI was associated with a higher mortality with advancing age (coefficient=0.1033, p=0.042). CONCLUSIONS: PCI was associated with a markedly lower rate of early stroke in octogenarians as compared to CABG. All-cause mortality was comparable between the two arms with a trend favoring CABG at ≥36-months.PCI was however associated with increasing mortality with advancing age as compared to CABG.
