Transcatheter Versus Surgical Aortic Valve Replacement in Intermediate-Risk Patients

Abstract

Introduction: Transcatheter aortic valve replacement (TAVR) is approved for severe aortic stenosis in all risk groups. However, long-term outcomes beyond 5 years in intermediate-risk patients compared to surgical AVR (SAVR) remain unclear. Methods: Systematic review of 5 RCTs (n=6,352) with 5-year follow-up (PARTNER 2, SURTAVI, NOTION). Inclusion: intermediate-risk (STS score 3–8%) or all-risk NOTION. Primary outcome: all-cause mortality. Secondary: stroke, permanent pacemaker implantation (PPM), valve thrombosis, reintervention. Results: All-cause mortality at 5 years was similar (TAVR 38.2% vs SAVR 38.9%, HR 0.96, 95% CI 0.86–1.07). Stroke rates also similar (7.5% vs 8.1%). TAVR had higher PPM (21% vs 12%, p<0.001) and paravalvular leak (moderate-severe: 3.5% vs 0.6%, p<0.001). SAVR had more new-onset atrial fibrillation (38% vs 16%). Valve thrombosis was rare (0.8% vs 0.3%). Discussion: Mortality equivalence is reassuring, but PPM and paravalvular leak remain TAVR limitations. Younger patients may prefer SAVR for durability. Conclusion: TAVR is non-inferior to SAVR for mortality at 5 years in intermediate-risk patients. Valve selection should consider age, anatomy, and pacemaker risk.