Transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis: a systematic review and meta-analysis

The optimal revascularization strategy for low-risk patients with severe aortic stenosis (AS), transcatheter (TAVI) versus surgical aortic valve replacement (SAVR), remains a subject of ongoing debate, particularly regarding long-term outcomes. We aimed to synthesize the evidence on the comparative safety and efficacy of TAVI and SAVR in this population. We conducted a systematic review and meta-analysis, searching PubMed, Scopus, Web of Science, and Cochrane Library until March 2025. We included randomized controlled trials (RCTs) and comparative observational studies enrolling low-risk patients with severe AS. Primary outcomes were all-cause mortality and stroke, analyzed at different time points. Data were pooled using random-effects models, with subgroup analyses based on study design. Thirty studies, including 48,210 patients, were included. TAVI was associated with a significantly lower risk of 30-day mortality (Relative Risk [RR] 0.66, 95% CI 0.50–0.76) and 30-day stroke (RR 0.70, 95% CI 0.53–0.92). However, in the overall analysis, SAVR was favored for one-year mortality (RR 1.11, 95% CI 1.01–1.21), with equipoise in long-term follow-up. TAVI significantly reduced the risks of 30-day major bleeding (RR 0.38, 95% CI 0.21–0.70) and atrial fibrillation (RR 0.41, 95% CI 0.22–0.76). Conversely, TAVI was associated with a persistently higher risk of permanent pacemaker implantation (RR 2.44 at 30 days, 95% CI 1.76–3.40) and paravalvular leakage (RR > 5-fold at both 30 days and 1 year). In low-risk patients with severe AS, TAVI offers clear early procedural safety advantages, particularly regarding stroke, bleeding, and atrial fibrillation. While the overall analysis suggested a 30-day mortality benefit for TAVI and a 1-year mortality benefit for SAVR, these findings were driven principally by observational data and were not statistically significant in the subgroup of randomized controlled trials. These procedural benefits are counterbalanced by a persistently higher risk of permanent pacemaker implantation and paravalvular leakage with TAVI. The choice of intervention requires a nuanced, individualized approach through shared decision-making, weighing early recovery benefits against device-related risks and the divergence between trial and registry outcomes.