Transcatheter versus surgical aortic valve replacement in patients with aortic stenosis with a small aortic annulus: A meta-analysis with reconstructed time to event data

Background: Aortic stenosis (AS) remains a prevalent and serious global health concern, exacerbated by an aging population worldwide. This valvular disease, when symptomatic and without appropriate intervention, severe AS can drastically reduce life expectancy. In our systematic review and meta-analysis, we aim to synthesize available evidence to guide clinical decision-making by comparing the performance of TAVR and SAVR, specifically in patients with severe AS and a small aortic annulus. Methods: We searched PubMed, EMBASE, Cochrane, Web of Science, and Scopus from inception till May 2024. The risk ratio (RR) and mean difference (MD) with a 95 % confidence interval (CI) are provided as effect size estimates, with all analyses being conducted using RevMan 5.4. Results: Eleven studies with 3,670 patients were included. TAVR significantly increased the risk of 2-year new permanent pacemaker implantation (PPI) (RR = 2.42; 95 % CI: [1.70-3.44], P < 0.0001) and major vascular complications (RR = 3.73; 95 % CI: [1.98-6.99], P < 0.0001) than SAVR. However, TAVR significantly decreased the risk of patient-prosthesis mismatch (PPM) (RR = 0.56; 95 % CI: [0.48-0.65], P < 0.00001) and new-onset atrial fibrillation (AF) (RR = 0.31; 95 % CI: [0.23-0.41], P < 0.00001). Also, SAVR reduced the risk of paravalvular leak (PVL) (RR = 3.35; 95 % CI: [1.79-6.27], P = 0.0002). Conclusion: TAVR had a significantly reduced risk of PPM and new-onset AF but with increased PPI and vascular complications. Also, TAVR significantly improved EOA and iEOA. Furthermore, SAVR had less risk of PVL, and better LVEF improvement at predischarge. Therefore, TAVR and SAVR remain valid alternatives, and decisions should be based on anatomy of the annulus and aortic root,operative risk, and comorbidities.