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Transfemoral TAVI is superior to SAVR in elderly high-risk patients with symptomatic severe aortic stenosis!

This editorial refers to ‘Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of severe aortic stenosis: a meta-analysis of randomized trials’, by G.C. Siontis et al. doi: 10.1093/eurheartj/ehw225. 

When transcatheter aortic valve implantation (TAVI) was first introduced, it was tested in clinical trials as a strategy against the gold standard treatment for symptomatic severe aortic stenosis, namely surgical aortic valve replacement (SAVR).1,2 Two first-generation valves (the Edwards Sapien Valve and Medtronic CoreValve) were studied in high surgical risk patients. In Cohort A of the PARTNER Trial, that TAVI should be non-inferior to surgery was seen as a major achievement for a first-generation valve.1 That TAVI might have superior outcomes to surgery, as suggested in the US PIVOTAL CoreValve Trial High Risk Cohort, was a surprise to many.2 Most commentators questioned ‘How did TAVI get so good?’ The US Pivotal Trial was the first TAVI trial to mandate rigorous computed tomography (CT) angiography pre-case planning, and changed practice as a result. It was carried out in the highest performing North American centres, with surgeons and interventionists of impeccable pedigree, and experienced proctors supervised many of the implants. Whilst it was clear that second-generation valves would be even better, the question remained if other trials would have similar findings.

In this issue of the journal, Siontis and colleagues present a meta-analysis of four trials comparing TAVI with SAVR, comprising >3000 patients.3 They have included two trials, the NOTION Trial (the only completed TAVI vs. SAVR trial outside of North America), and the first TAVI Trial in a slightly less high risk patient population, PARTNER 2A in which patients were randomized to receive either the second-generation SAPIEN …