Outcomes of transcatheter aortic valve replacement in younger low-risk patients: a comprehensive meta-analysis of efficacy and safety

Background and aims: Severe aortic stenosis (AS) was traditionally managed with surgical aortic valve replacement (SAVR). Transcatheter aortic valve implantation (TAVI) emerged as a less invasive alternative, initially for high-risk patients. This meta-analysis evaluates the outcomes of TAVI in younger, low-risk patients, in whom SAVR is currently the gold standard. Methods: Following PRISMA guidelines, we systematically searched randomized controlled trials (RCTs) comparing TAVI with SAVR in younger (mean age <75 years) low-risk patients (STS score <4%) with severe AS. The primary endpoint was a composite of death or disabling stroke. Secondary endpoints included all-cause mortality, disabling stroke, atrial fibrillation (AF), permanent pacemaker implantation (PPI), bleeding, functional class (NYHA), and quality-of-life (KCCQ score) improvements. Results: Four RCTs were included with 4,252 patients (2,125 TAVI and 2,127 SAVR). At a mean follow-up of 16 ± 5 months, TAVI showed a non-significant reduction in the composite of death or disabling stroke [2.8% vs. 5.1% risk ratio (RR) 0.98, 95% confidence interval (CI) (0.96–1.00), p = 0.11] and all-cause mortality [2.1% vs. 3.7%, RR 0.99, 95% CI (0.97–1.00), p = 0.15]. The incidence of disabling stroke was significantly lower in TAVI [0.9 vs. 2.1 RR 0.99, 95% CI (0.98–1.00), p < 0.01]. Hospital readmission [7.1% vs. 9.5% RR 0.97, 95% CI (0.96–0.99), p < 0.01] and bleeding rates [4.7% vs. 16%, RR 0.87, 95% CI (0.82–0.93), p < 0.01] were significantly lower in the TAVI group. Conversely, TAVI had a higher PPI rate [14% vs. 6%, RR 1.08, 95% CI (1.02–1.14), p < 0.01]. Faster symptomatic and quality-of-life improvements were sustained in the TAVI group. Conclusions: TAVI is a viable option for younger low-risk patients with severe AS, being non-inferior to SAVR in short-term outcomes. The benefits of TAVI include a lower risk of disabling stroke, hospital readmission, and bleeding, as well as quicker improvements in symptoms and quality of life. However, higher PPI rates require careful patient selection. The results support a tailored approach to TAVI in younger patients, with ongoing evaluation of long-term outcomes. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD42024559473, PROSPERO (CRD42024559473).