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Address for reprints: Yosuke Sakurai, MD, Department of Surgery, Marshall University Joan Edwards School of Medicine, 1600 Medical Center Dr, Huntington, WV 25701.
Toshiki Kuno, MD, PhD, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, NY 10467–2401.
Bicuspid aortic valves have been excluded from randomized trials comparing transcatheter aortic valve replacement with surgical aortic valve replacement. We aimed to evaluate the outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients with severe bicuspid aortic valve stenosis using a meta-analysis.
Methods
MEDLINE and EMBASE were searched through March 2022 to identify observational studies comparing transcatheter aortic valve replacement and surgical aortic valve replacement for severe bicuspid aortic valve stenosis. Outcomes of interest were in-hospital outcomes, including all-cause mortality, stroke, vascular complication, permanent pacemaker implantation, acute kidney injury, blood transfusion, paravalvular leak, and all-cause mortality during follow-up.
Results
Four propensity score–matched studies and 54,047 patients (transcatheter aortic valve replacement, n = 3841; surgical aortic valve replacement, n = 50,206) yielding 3142 pairs using propensity score were included. Median follow-up periods were 21 to 24 months. There were no significant differences in in-hospital mortality (risk ratio, 0.69; 95% confidence interval, 0.40-1.20; P = .19) or stroke (risk ratio, 0.86; 95% confidence interval, 0.64-1.14; P = .29). Although transcatheter aortic valve replacement was associated with higher risks of permanent pacemaker implantation rate (risk ratio, 1.87; 95% confidence interval, 1.23-2.84; P = .0003), transcatheter aortic valve replacement was associated with lower risks of acute kidney injury (risk ratio, 0.58; 95% confidence interval, 0.38-0.88; P = .01) and transfusion (risk ratio, 0.25; 95% confidence interval, 0.21-0.29; P = .0001). There were no significant differences in in-hospital vascular complication, paravalvular leak, and all-cause mortality during follow-up.
Conclusions
In selected patients with severe bicuspid aortic valve stenosis, no significant differences in in-hospital mortality or stroke were observed between transcatheter aortic valve replacement and surgical aortic valve replacement. Further investigations with long-term follow-up and morphological features are warranted.
In-hospital mortality or stroke did not differ between TAVR and SAVR in patients with severe bicuspid aortic stenosis. Long-term comparative studies with morphological features are still needed.
In this meta-analysis of comparative studies for TAVR versus SAVR among 6284 patients with BAV, there were no significant differences in in-hospital mortality or stroke between TAVR and SAVR, whereas long-term outcomes are limited. Long-term comparative studies with detailed morphological features are needed to identify the patient population who would benefit the most from TAVR.
Bicuspid aortic valve (BAV) is the most common congenital cardiac disease, which frequently results in aortic stenosis requiring aortic valve intervention at a younger age in comparison with tricuspid aortic valve (TAV) stenosis.
Transcatheter aortic valve replacement (TAVR) is a valid alternative to surgical aortic valve replacement (SAVR) since indications have been expanded to low-risk patients with symptomatic severe aortic stenosis with TAV.
The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on transcatheter and surgical aortic valve replacement in low- and intermediate-risk patients: a meta-analysis of randomized and propensity-matched studies.
Meta-analysis of effectiveness and safety of transcatheter aortic valve implantation versus surgical aortic valve replacement in low-to-intermediate surgical risk cohort.
Numerous studies compared outcomes of TAVR for BAV with TAV, which showed conflicting results with potential higher risks of stroke and paravalvular leak (PVL) in patients with BAV.
Moreover, although recent registry data showed comparable risks of 1-year mortality, stroke, or PVL undergoing TAVR using new-generation devices between BAV and TAV,
those results could not be extrapolated to outcomes of SAVR for patients with BAV.
In addition to the paucity of comparative data between TAVR and SAVR among patients with BAV, those conflicting data highlight the importance of head-to-head comparison of TAVR versus SAVR to provide better guidance for clinical decision-making. We conducted a meta-analysis comparing the outcomes of TAVR versus SAVR for patients with severe BAV stenosis.
Materials and Methods
The review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
and was prospectively registered with the PROSPERO (CRD42022329713).
Search Strategy and Eligibility
All RCTs and observational studies with comparative outcomes of TAVR and SAVR for BAV were considered using MEDLINE and EMBASE. Databases were searched through March 22, 2022, using web-based search engines (PubMed and OVID). Search terms included “transcatheter aortic valve replacement,” “transcatheter aortic valve implantation,” “bicuspid aortic valve,” and “surgical aortic valve replacement.” No language or sample size restrictions were applied. This systematic review was based on PICOS Frameworks as follows: P (Population), patients with stenotic BAV who underwent either TAVR or SAVR; I (Intervention), TAVR; C (Comparison), SAVR; O (Outcome), in-hospital outcomes including all-cause mortality, stroke, PVL, acute kidney injury, bleeding requiring blood transfusion, vascular complication, and permanent pacemaker implantation, as well as all-cause mortality at the longest follow-up; and S (Study type), RCTs and observational studies.
Included studies met the following criteria: The study design was an RCT or observational study, the study population was patients with BAV who underwent TAVR or SAVR, and comparative outcomes included in-hospital mortality, stroke, any PVL, acute kidney injury, bleeding requiring blood transfusion, permanent pacemaker implantation, vascular complication, and all-cause mortality during follow-up. We excluded case reports, case series, and studies not reporting any adjusted outcomes.
Study Selection and Data Collection
Relevant studies were identified through a manual search of secondary sources including references of initially identified articles, reviews, and commentaries. All references were downloaded for consolidation, elimination of duplicates, and further analyses. Two independent authors (Y.S. and Y.Y.) reviewed the search results separately to select the studies based on present inclusion and exclusion criteria. Disagreements were resolved by consensus. The quality of the studies was assessed using the Cochrane Collaboration tool for RCTs and the Risk of Bias in Non-Randomized Studies of Interventions tool.
The primary end points were in-hospital mortality and stroke. The secondary end points were in-hospital periprocedural outcomes, including PVL, acute kidney injury, bleeding requiring blood transfusion, permanent pacemaker implantation, vascular complication, and all-cause mortality at the longest follow-up on each study. For each in-hospital outcome, risk ratios (RRs) were calculated from the event number and the patient number. Odds ratios without reporting events number were transformed to RRs using a validated formula.
For all-cause mortality at follow-up, hazard ratios (HRs) were extracted from each study. For studies not describing HRs, the HR was calculated from a Kaplan–Meier curve of the matched population using a spreadsheet programmed to estimate the overall HR with a 95% confidence interval (CI) with an inverse variance–weighted average, which is provided by Tierney and colleagues,
The Review Manager (RevMan) Version 5.4 (Nordic Cochrane Centre, the Cochrane Collaboration, 2012) was used to combine RRs or HRs in the random-effects model with inverse variance method. The random-effects model was used in each outcome regardless of the heterogeneity among studies, because it allowed for a more conservative assessment of the pooled effect size.
Funnel-plot asymmetry was examined, and sensitivity analyses were conducted using ProMeta 3 Software (https://idostatistics.com/prometa3/). Funnel plot asymmetry suggesting publication bias was assessed mathematically using Egger's linear-regression test. Substantial heterogeneity was considered to be present when the I2 index was more than 50% or P for heterogeneity was less than .05. Leave-one-out sensitivity analyses for in-hospital mortality and stroke were conducted to assess the influence of a single study on outcomes by sequentially removing one study.
A meta-regression analysis was conducted to evaluate the relationship between mean age or median year of enrollment of each study and in-hospital mortality or stroke.
Results
Study Selection
The database search identified 797 articles that were reviewed based on the title and abstract. Of those, 19 articles were considered relevant for the meta-analysis. After evaluating the full-text articles, 15 articles were excluded for the following reasons: 3, no outcomes of interest; 5, no comparison with SAVR; 1, overlapping dataset; 1, review; 1, commentary; 4, meta-analysis. Four articles published from 2019 to 2022 met the inclusion criteria and were assessed for the systematic review and meta-analysis (Figure 1). All 4 studies were propensity score matched
and enrolled a total of 54,047 patients (TAVR, n = 3841; SAVR, n = 50,206), yielding 3142 pairs using propensity score.
Figure 1Workflow for selecting eligible articles according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria in search of original studies for our original meta-analysis.
(Table E1) without reporting of the grade of PVL or vascular complication. Study periods ranged from 2008 to 2018. Two studies reported outcomes from the National Inpatient Sample (NIS) or Nationwide Readmission Database (NRD)
; however, the study periods did not overlap. The exclusion criteria of each study are described in Table E2. Most studies excluded patients undergoing concomitant ascending aortic replacement, coronary artery bypass grafting (CABG), or other valvular intervention. Before propensity score matching, the TAVR population was older than the SAVR group (mean age, 66.2-77.1 years vs 56.9-70.9 years)
with a higher prevalence of comorbidities, including diabetes, chronic lung disease, chronic kidney disease, prior CABG, and prior percutaneous coronary intervention (Table E3). After propensity matching, there were no significant differences in the baseline characteristics (Table 1). Variables to generate the propensity score in each study are summarized in Table E4. Mean age of patients was 65.2 to 75.8 years.
The other 3 studies mainly included patients at intermediate risk because TAVR was not approved in the United States for low-risk patients during the study period.
The type or generation of transcatheter valves was described in one study reporting that 81.6% were new-generation devices and 77.7% were balloon-expandable valves.
Other anatomic features, including raphe calcification, excess leaflet calcification, or ascending aorta diameter, were not described. The risk of bias is summarized in Table E5, showing that all studies were considered as a moderate risk of bias. Publication bias in each outcome was assessed using funnel plots (Figure E1), which showed no evidence of publication bias except for in-hospital stroke and blood transfusion.
Table 1Baseline study and patient characteristics in the matched cohorts
Author
Publication year
Study period
Dataset
Adjustment
Patient number (n)
Age
Female (%)
Hypertension (%)
Diabetes mellitus (%)
Smoke (%)
COPD (%)
Chronic kidney disease (%)
Left ventricular ejection fraction <30% (%)
Total
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
Elbadawi
2019
2012-2016
National Inpatient Sample
PSM
1950
975
975
65.7
65.2
40
36.4
64.6
64.6
29.7
30.8
20.5
20
32.3
25.6
19.5
24.1
NA
NA
Mentias
2020
2015-2017
Medicare
PSM
1398
699
699
72.2
72.8
40
40
88
88
36
37
17
16
38
38
27
28
NA
NA
Husso
2021
2008-2017
Finn Valve Registry
PSM
150
75
75
75.8
75.7
44
45.3
NA
NA
21.3
14.7
NA
NA
NA
NA
NA
NA
4.1
4
Majmunder
2022
2016-2018
Nationwide Readmission Database
PSM
2786
1393
1393
68.3
68.1
37.8
38.4
78.8
75.6
28
29.4
36.8
34.3
31.3
28.7
23.8
23.8
NA
NA
Stroke/TIA (%)
Peripheral artery disease (%)
Prior CABG (%)
Prior PCI (%)
euroSCORE II
STS PROM
Bicuspid aortic valve type
TAVR access
TAVR valve used
Concomitant procedure with SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR
SAVR
TAVR/SAVR
TAVR
TAVR
SAVR
9.2
11.3
27.7
30.3
10.3
8.7
8.7
7.2
NA
NA
NA
NA
NA
Transapical 10.8% (n = 105)
NA
NA
13
12
37
35
NA
NA
13
16
NA
NA
NA
NA
NA
NA
NA
CABG 24% Ascending aorta surgery 11%
8
9.3
9.3
10.7
5.3
8
16
8
4.0
3.8
2.9 ± 1.7
3.1 ± 3.2
Type 0; 16.5% Type 1; 81.6% Type 2; 1.9%
Transapical 6.7% (n = 5)
New Generation 81.6% (Sapien, Edwards Lifesciences, 3 (n = 63), Evolut R/CoreValve, Medtronic, (n = 8), Lotus, Boston Scientific, (n = 11), Accurate Neo, Boston Scientific, (n = 2)) Old Generation 18.4% (Medtronic CoreValve (n = 2), Edwards Sapient XT (n = 17))
CABG 25.3%
6.8
6.8
26.4
25.5
5.8
6.7
10.2
9.7
NA
NA
NA
NA
NA
NA
NA
NA
COPD, Chronic obstructive pulmonary disease; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement; PSM, propensity score match; NA, not available; TIA, transient ischemic attack; CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; euroSCORE, European System for Cardiac Operative Risk Evaluation; STS PROM, Society of Thoracic Surgeons predicted risk of mortality.
There was no significant difference in in-hospital mortality (RR, 0.69; 95% CI, 0.40-1.20; P = .19; I2 = 49%), or stroke (RR, 0.86; 95% CI, 0.64-1.14; P = .29; I2 = 0%) (Figure 2, A and B). TAVR was associated with higher risks of permanent pacemaker implantation (RR, 1.87; 95% CI, 1.23-2.84; P = .0003; I2 = 80%) (Figure 3, A). In contrast, TAVR was associated with a lower rate of acute kidney injury (RR, 0.58; 95% CI, 0.38-0.88; P = .01; I2 = 89%) and transfusion (RR, 0.25; 95% CI, 0.21-0.29; P = .0001; I2 = 0%) (Figure 3, B and C). Vascular complications (RR, 0.58; 95% CI, 0.18-1.91; P = .37; I2 = 74%) and PVL (RR, 1.56; 95% CI, 0.85-2.85; P = .15; I2 = 0%) were similar in both groups (Figure 3, D and E).
Figure 2Comparisons of the in-hospital (A) all-cause mortality and (B) stroke for TAVR versus SAVR using a random effects model. Left: Studies analyzed with their corresponding HRs and 95% CIs. Right: Forest plot of the data. The horizontal lines represent the values within the 95% CI of the underlying effects. The vertical line indicates an HR of 1. SE, Standard error; IV, inverse variance; CI, confidence interval; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement.
Figure 3Comparisons of the periprocedural outcomes for TAVR versus SAVR using a random effects model. A, Permanent pacemaker implantation. B, Acute kidney injury. C, Blood transfusion. D, Major vascular complication. E, Any PVL. Left: Studies analyzed with their corresponding HRs and 95% CIs. Right: Forest plot of the data. The horizontal lines represent the values within the 95% CI of the underlying effects. The vertical line indicates an HR of 1. SE, Standard error; IV, inverse variance; CI, confidence interval; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement.
Figure 3Comparisons of the periprocedural outcomes for TAVR versus SAVR using a random effects model. A, Permanent pacemaker implantation. B, Acute kidney injury. C, Blood transfusion. D, Major vascular complication. E, Any PVL. Left: Studies analyzed with their corresponding HRs and 95% CIs. Right: Forest plot of the data. The horizontal lines represent the values within the 95% CI of the underlying effects. The vertical line indicates an HR of 1. SE, Standard error; IV, inverse variance; CI, confidence interval; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement.
There was no significant difference in all-cause mortality during follow-up with a median follow-up period of 21 to 36 months (HR, 0.83; 95% CI, 0.40-1.70; P = .60; I2 = 67%) (Figure 4).
Figure 4Comparisons of all-cause mortality during follow-up for TAVR versus SAVR using a random effects model. Left: Studies analyzed with their corresponding HRs and 95% CIs. Right: Forest plot of the data. The horizontal lines represent the values within the 95% CI of the underlying effects. The vertical line indicates an HR of 1. SE, Standard error; IV, inverse variance; CI, confidence interval; TAVR, transcatheter aortic valve replacement; SAVR, surgical aortic valve replacement.
Leave-one-out analyses did not indicate any significant effect on in-hospital mortality or stroke with any one study being removed (Figure E2, A and B). A meta-regression model investigating the effects of changes in practice over time did not reveal a significant relationship between the median year of enrollment and in-hospital mortality or stroke (Figure E3, A and B). In addition, there was no significant association between mean age at baseline and in-hospital mortality or stroke (Figure E4, A and B).
Discussion
The main findings of our meta-analysis of comparative studies for TAVR and SAVR in patients with stenotic BAV are as follows (Figure 5): (1) There was no significant difference in in-hospital mortality, stroke, PVL, or vascular complications between TAVR and SAVR; (2) TAVR was associated with lower risks of acute kidney injury or any transfusion; (3) TAVR was associated with higher risks of permanent pacemaker implantation than SAVR; and (4) there was no significant difference in all-cause mortality during follow-up with a median follow-up of 21 to 24 months. Our main findings were in line with previous RCTs for TAVR versus SAVR in patients with TAV,
In this regard, the short-term feasibility of TAVR was supported by comparable risks of stroke between TAVR and SAVR in this study. However, the risks of stroke were still relatively high ranging from 2.1% to 4.0% among the studies, which we included with a mean age of 68 to 75 years. Similar numerically higher risks of stroke were observed in a prospective registry of BAV TAVR, even among low-risk populations.
Previous studies showed that longer procedure duration and postdilation during TAVR, which are associated with unique morphological features of BAV, were independent predictors of new ischemic lesions.
These observations underscore the need for further studies to elucidate the potential efficacy of the cerebral embolic protection devices for patients undergoing TAVR for BAV stenosis.
Additionally, our analysis demonstrated lower risks of periprocedural complication with TAVR, including acute kidney injury and blood transfusion, along with comparable risks of vascular complication, supporting the feasibility of TAVR despite the complexity of the TAVR procedure for BAV. Relevantly, cardiac tamponade, pericardiocentesis, or an open conversion after TAVR were extremely rare among the studies that we included.
those findings would add another piece of reassuring information that TAVR can be safely performed for BAV in comparison with SAVR. Likewise, we did not find significant differences in PVL rates between TAVR and SAVR, whereas previous studies showed higher risks of PVL after TAVR for BAV compared with TAV.
However, only 2 of 4 studies reported the incidence of PVL, and we could not account for the grades of PVL. Because the incidence of mild PVL after TAVR is consistently higher than SAVR even with the new-generation devices,
Our systematic review revealed limited data on long-term comparative outcomes with morphological features of BAV between TAVR and SAVR, whereas the long-term outcome of SAVR for BAV has been well established and promising.
Prevalence of permanent pacemaker implantation after conventional aortic valve replacement-a propensity-matched analysis in patients with a bicuspid or tricuspid aortic valve: a benchmark for transcatheter aortic valve replacement.
Additionally, the present analysis data cannot necessarily be extrapolated to outcomes of patients who need concomitant surgical procedures because many studies excluded those patients. Interestingly, ascending aortic dilation (>40 mm) is reported as an independent factor of long-term mortality after TAVR as opposed to SAVR.
potentially playing a role in conflicting reported outcomes of TAVR with these discrepancies. Although our analysis did not include granular data on ascending aorta diameter, because SAVR with concomitant ascending aorta replacement can be performed without adding morbidity,
patients with aortopathy who are surgical candidates should undergo surgical repair. Moreover, imaging-based anatomic risk assessment of TAVR is an essential part of the heart team discussion because BAV anatomy is highly heterogenous and calcified raphe or excess leaflet calcification is unfavorable for TAVR.
In this context, long-term follow-up data with detailed anatomic features are of key importance in the selection of appropriate treatment strategies between TAVR and SAVR. Furthermore, the impacts of long-term pacing need to be carefully investigated given the higher risks of permanent pacemaker implantation after TAVR in our analysis because patients undergoing TAVR for BAV tend to have a long life expectancy, and a previous meta-analysis showed that pacemaker implantation was independently associated with increased all-cause mortality after TAVR for TAV.
Ultimately, well-designed randomized trials are warranted to validate the present findings. Nevertheless, because there are no upcoming randomized trials and it might be difficult to conduct an RCT given the complexity of the BAV,
the current comparable outcomes with real-world patients would support the feasibility of TAVR among the selected patients with BAV.
Study Limitations
This study has several limitations. No randomized studies were included in this analysis, observational studies are subject to confounding, and studies using administrative data are subject to coding errors, although the NIS database is internally and externally validated.
Furthermore, 2 studies included patients undergoing SAVR with concomitant CABG or ascending aorta replacement, which may compromise the comparability between TAVR and SAVR. However, both studies conducted the sensitivity analysis excluding patients undergoing the concomitant procedures, confirming the robustness of the primary analysis. Nevertheless, the HRs of those sensitivity analyses were not reported, precluding us from conducting another analysis for patients undergoing isolated SAVR. On the other hand, a small portion of the TAVR was performed via transapical access, which could lead to worse outcomes in the TAVR group. Nevertheless, despite the heterogeneities in the study population and potential publication bias, we only included propensity score–matched studies with well-balanced baseline characteristics and almost identical variables to generate the propensity scores. Second, analyzing and comparing granular datasets were not possible, particularly related to individual anatomic features or details of the procedure including aortic diameter, excess leaflet calcifications, raphe calcification, the frequency of pre- or postdilation during TAVR, type of TAVR valve, and use of the cerebral embolic protection devices. Notably, TAVR tended to be performed on selected patients with favorable anatomy, limiting the generalizability of this study. Finally, the effect of potential overlapping cohorts in the Medicare, NIS, or NRD based studies could not be excluded. However, 2 studies from the NIS and the NRD database were not overlapped based on the enrollment year.
Moreover, the leave-one-out analyses showed that removal of any of those studies did not change the robustness of the results. Therefore, we presume that the effect of overlapping patients might be minimal.
Conclusions
In selected patients with BAV stenosis, TAVR was associated with similar in-hospital mortality or stroke compared with SAVR. Long-term comparative data need to be investigated with detailed morphological features.
Conflict of Interest Statement
A.L. is a consultant for and on the advisory board of Medtronic, Abbott, Boston Scientific, Edwards Lifesciences, and Philips. V.H.T. is a research/advisor for Abbott Vascular, Artivion, AtriCure, Boston Scientific, Edwards Lifesciences, JenaValve, Medtronic, and Shockwave. T.K. has received consulting fees from Edwards Lifesciences, Medtronic, 4C Medical, CardioMech, and Cook Medical; and has been a speaker for Abbott and Baylis. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Appendix E1
Figure E1Funnel plots for assessment for publication bias for in-hospital outcomes. A, All-cause mortality. B, Stroke. C, Acute kidney injury. D, Permanent pacemaker implantation. E, Blood transfusion. F, Vascular complication.
Figure E2Forest plot of the leave-one-out analysis for (A) in-hospital mortality and (B) in-hospital stroke. Pooled estimates are calculated by omitting one study at a time. A study name indicates the omitted study. ES, Effect size (HR); CI, confidence interval; Sig, P value; N, patient number.
KDIGO criteria postoperative increase of creatinine ≥ 1.5 times, increase of creatinine ≥ 26.5 mmol/L, or need for renal replacement therapy
NA
Majmunder
2022
ICD-9 or ICD-10 codes as follows I60, I61, I62, I690, I691, I692, I63, G46, I61, I629, I97810, I97811, I97820, I97821
ICD-9 or ICD-10 codes as follows T8203, T82223
Bleeding requiring any blood transfusion
NA
ICD-9 or ICD-10 codes as follows N170, N171, N172, N178, N179, N19, N990, R34
NA
ICD, International Classification of Diseases; NA, not available; VARC-2, Valve Academic Research Consortium-2; KDIGO, Kidney Disease: Improving Global Outcomes.
Age <18 y, concomitant aortic root repair, CABG, other valvular heart surgeries or atrial or ventricular septal defect repair, isolated aortic regurgitation
Mentias
2020
2015-2017
Concomitant mitral valve surgery
Husso
2021
2008-2017
Age < 18 y, previous surgical or transcatheter intervention on the aortic valve, acute endocarditis, isolated aortic valve regurgitation, or major concomitant other valve or thoracic aortic procedures
Majumdar
2022
2016-2018
Age < 18 y, concomitant CABG, mitral, pulmonary, and tricuspid valve surgeries atrial or ventricular sepal defect repair, and aortic root surgery
Age, sex, body mass index, hemoglobin, estimated glomerular filtration rate according to the Chronic Kidney Disease Epidemiology Collaboration equation, diabetes, stroke, pulmonary disease, atrial fibrillation, extracardiac arteriopathy, New York Heart Association class IV, Geriatric Frailty Status Scale 2-3, urgent/emergency procedure, prior pacemaker, acute heart failure within 60 d from the index procedure, prior cardiac surgery, prior percutaneous coronary intervention, left ventricular ejection fraction ≤ 50%, number of diseased vessels and STS score.
The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on transcatheter and surgical aortic valve replacement in low- and intermediate-risk patients: a meta-analysis of randomized and propensity-matched studies.
Meta-analysis of effectiveness and safety of transcatheter aortic valve implantation versus surgical aortic valve replacement in low-to-intermediate surgical risk cohort.
The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
Prevalence of permanent pacemaker implantation after conventional aortic valve replacement-a propensity-matched analysis in patients with a bicuspid or tricuspid aortic valve: a benchmark for transcatheter aortic valve replacement.
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