Outcomes of transcatheter aortic valve replacement in younger low-risk patients: a comprehensive metaanalysis of efficacy and safety

António Rocha De Almeida^1,2*Maria Rita Lima³Daniel Gomes MD³Renato Fernandes¹Eduardo Infante Oliveira³Pedro Araújo Gonçalves^3,4Rui Teles^3,4Manuel De Sousa Almeida^3,4Lino Patrício¹

• ¹Hospital Espírito Santo, Évora, Portugal
• ²Católica Biomedical Research Centre, Faculty of Medicine, Catholic University of Portugal, Oeiras, Portugal
• ³Hospital Santa Cruz , ULSLO, Lisboa, Portugal
• ⁴Comprehensive Health Research Center, New University of Lisbon, Lisboa, Portugal

Abstract Background and Aims Severe aortic stenosis (AS) was traditionally managed with surgical aortic valve replacement (SAVR). Transcatheter aortic valve implantation (TAVI) emerged as a less invasive alternative, initially for high-risk patients. 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 younger (mean age < 75 years) low-risk patients (STS score <4%) with severe 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. Results Four RCTs were included with 4252 patients (2125 TAVI and 2127 SAVR). At a mean follow-up of 16±5 months, TAVI showed a non-significant reduction in the composite of death or disabling stroke (2.8% vs. 5.1% RR 0.98, 95% CI [0.96-1.00], p=0.11), and all-cause mortality (2.1% vs. 3.7%, RR 0.99, 95% CI [0.97-1.00], p=0.15). The incidence of disabling stroke was significantly lower in TAVI (0.9 vs. 2.1 RR 0.99, 95% CI [0.98-1.00], p<0.01). Hospital readmission (7.1% vs. 9.5% RR 0.97, 95% CI [0.96-0.99], p<0.01) and bleeding rates (4.7% vs. 16%, RR 0.87, 95% CI [0.82-0.93], p<0.01) were significantly lower in the TAVI group. Conversely, TAVI had a higher PPI rate (14% vs. 6%, RR 1.08, 95% CI [1.02-1.14], p<0,01). Faster symptomatic and quality of life improvements were sustained in the TAVI group. Conclusions TAVI is a viable option for younger low-risk patients with severe AS, being non-inferior to SAVR in short-term outcomes. The benefits of TAVI include a lower risk of disabling stroke, hospital readmission, and bleeding, as well as quicker improvements in symptoms and quality of life. However, higher PPI rates require careful patient selection. The results support a tailored approach to TAVI in younger patients, with ongoing evaluation of long-term outcomes.