Transcatheter aortic valve implantation vs surgical replacement in low-risk aortic stenosis: time-dependent late mortality in a pooled analysis of trials

The expansion of transcatheter aortic valve implantation (TAVI) to low-risk patients with severe aortic stenosis (AS) has been driven by randomized trials reporting favourable early outcomes and non-inferiority to surgical aortic valve replacement (SAVR), through early and intermediate follow-up.1 However, longer-term assessment is essential for patients with a longer life expectancy, in whom durability, reintervention risk, and survival are central to treatment selection.2 Recently released extended follow-up data from pivotal lower-risk trials have raised concerns that the early advantages of TAVI may attenuate over time, with emerging signals related to late mortality, valve durability, and reintervention.3–5 However, these trials were underpowered to evaluate all-cause mortality as an individual endpoint. Moreover, conventional time-to-event analyses may obscure clinically important time-dependent differences between two treatment strategies exhibiting non-parallel patterns of early and late risk. We therefore conducted a pooled reconstructed time-to-event analysis of randomized low-risk trials with extended follow-up of up to 7 years.