Elsevier

International Journal of Cardiology

Volume 228, 1 February 2017, Pages 327-334
International Journal of Cardiology

Direct and adjusted indirect comparisons of perioperative mortality after sutureless or rapid-deployment aortic valve replacement versus transcatheter aortic valve implantation

https://doi.org/10.1016/j.ijcard.2016.11.253Get rights and content

Abstract

Objectives

To determine which procedure, aortic valve replacement (AVR) with a sutureless or rapid-deployment prosthesis (SL-AVR) or transcatheter aortic valve implantation (TAVI), achieves better perioperative survival for severe aortic stenosis (AS), we conducted direct-comparison meta-analyses (DC-MAs) and an adjusted indirect-comparison meta-analysis (IDC-MA).

Methods

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through April 2016. Eligible studies were randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. We performed a DC-MA-[A] of SL-AVR versus TAVI, a DC-MA-[B] of SL-AVR versus conventional AVR (C-AVR), and a DC-MA-[C] TAVI versus C-AVR. Then, we computed a IDC-MA-[A′] of TAVI versus SL-AVR from the results of the DC-MA-[B] and the DC-MA-[C].

Results

We identified 6 RCTs and 30 PSM studies enrolling a total of 15,887 patients. The 3 DC-MAs demonstrated significantly lower perioperative (30-day or in-hospital) all-cause mortality after SL-AVR than after TAVI (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.28 to 0.80; p = 0.005) and no significant differences between SL-AVR and C-AVR (OR, 1.07; 95% CI, 0.60 to 1.94; p = 0.81) and between TAVI and C-AVR (1.07; 95% CI, 0.90 to 1.27; p = 0.45). The computed IDC-MA-[A′] indicated no significant difference in mortality between SL-AVR and TAVI (1.01; 95% CI, 0.54 to 1.86). Combining the results of the DC-MA-[A] and IDC-MA [A′] showed significantly lower mortality after SL-AVR than after TAVI (OR, 0.65; 95% CI, 0.44 to 0.97; p = 0.03).

Conclusions

For patients with severe AS, SL-AVR may achieve better perioperative survival than TAVI.

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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  • 1

    These authors contributed equally to this study.

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