Transcatheter aortic valve implantation in centers without a cardiac surgery department: a meta-analysis of contemporary evidence

Introduction
The prevalence of aortic stenosis (AS) is increasing, resulting in a growing demand for aortic valve interventions. Current guidelines recommend transcatheter aortic valve implantation (TAVI) only in centers with on-site cardiac surgery (CS) backup. However, procedural advancements have reduced the need for emergent cardiac surgery (ECS), prompting a debate about the necessity of backup for this procedure. This meta-analysis evaluated the safety of TAVI performed in centers without CS backup.

Material and methods
The study was conducted in accordance with the MOOSE guidelines. The protocol was registered at PROSPERO (CRD420251044095). PubMed, CENTRAL, and Scopus were systematically searched up to November 2025. Studies comparing outcomes of TAVI performed with and without on-site CS or reporting outcomes of TAVI in non-CS centers were included. The outcomes were in-hospital mortality, 30-day death, need for ECS, and stroke. Meta-analyses of comparative studies and pooled proportions were performed using random-effects models. Risk of bias was evaluated using the ROBINS-I tool.

Results
Eight observational studies were analyzed, including 22,203 patients (19,373 with and 2830 without on-site CS). No significant difference in in-hospital mortality was observed between groups (relative risk [RR] = 1.1, 95% CI: 0.6–1.9, p = 0.8). Thirty-day mortality was also similar (RR = 1.2, 95% CI: 0.5–2.6, p = 0.72). ECS did not occur (0%; 95% CI: 0–1), with an RR of 0.8 (95% CI: 0.2–2.4, p = 0.7). Stroke rates did not differ (RR = 1.1, 95% CI: 0.8–1.5). Pooled in-hospital mortality in non-surgical centers was 3% (95% CI: 1–4%), and 30-day mortality was 4% (95% CI: 2–6%). Sensitivity analyses in propensity score-matched populations confirmed findings with reduced heterogeneity and consistent results.

Conclusions
TAVI performed in centers without on-site cardiac surgery demonstrated comparable outcomes to those with surgical backup, suggesting that selected programs may safely operate under this model. These findings support reconsidering current guideline restrictions to enhance access and equity in TAVI delivery.