Direct and adjusted indirect comparisons of perioperative mortality after sutureless or rapid-deployment aortic valve replacement versus transcatheter aortic valve implantation
Introduction
Our preliminary meta-analysis [1] suggests that perioperative all-cause mortality is lower after aortic valve replacement (AVR) with a sutureless or rapid-deployment prosthesis (SL-AVR) than after transcatheter aortic valve implantation (TAVI) for severe aortic stenosis (AS). Statistical power of this meta-analysis [1], however, may be insufficient, because merely 7 observational comparative studies were included in it. Limited or no evidence is often obtained from direct-comparison (DC) studies, and thus an adjusted indirect comparison (IDC) may be required [2]. Additionally, to augment statistical power or precision, it would be possible to quantitatively combine results of the DC and those of the IDC [3]. To determine which procedure, SL-AVR or TAVI, achieves better perioperative overall survival for severe AS, a DC meta-analysis (DC-MA) and an IDC meta-analysis (IDC-MA) were performed, and then results of them were combined.
Section snippets
Methods
We identified all randomized controlled trials (RCTs) and propensity-score matched (PSM) studies of SL-AVR versus TAVI, those of SL-AVR versus conventional AVR (C-AVR), and those of TAVI versus C-AVR for severe AS by the use of a 2-level search strategy. First, we searched databases of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials by means of Web-based search engines of PubMed and OVID through April 2016. Second, we identified relevant studies via manual searching
Results
We identified 6 eligible studies [5], [6], [7], [8], [9], [10] of SL-AVR versus TAVI, 6 ones [9], [11], [12], [13], [14], [15] of SL-AVR versus C-AV, and 24 ones [9], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38] of TAVI versus C-AVR (Table 1). These included no RCT and 6 PSM studies [5], [6], [7], [8], [9], [10] (enrolling a total of 1478 patients) of SL-AVR versus TAVI, one RCT [11] (including 94
Discussion
In the present analysis of RCTs and PSM studies, the DC demonstrated significantly lower perioperative all-cause mortality after SL-AVR than after TAVI, whereas the IDC indicated no statistically significant difference in mortality between SL-AVR and TAVI. Even adding the result of the IDC to that of the DC (combining the result of the DC and that of the IDC), however, showed still significantly lower mortality after SL-AVR than after TAVI. The final analysis included 36 studies enrolling a
Conclusions
The present analysis, which combined the result of the DC-MA and that of the IDC-MA and included 36 studies enrolling a total of approximately 16,000 patients with severe AS, suggests that SL-AVR may achieve better perioperative overall survival than TAVI. Lower prevalence of PAR and PMI may explicate lower mortality after SL-AVR than after TAVI. Assumptions concerning IDC, however, are more complex than the underlying assumption for standard meta-analysis (DC-MA). Further DC studies
Conflicts of interest
None.
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These authors contributed equally to this study.