Figure 1
PRISMA diagram. TAVI, transcatheter aortic valve implantation.
Table 1
NOS quality scores.
| Author, year | Selection (0–4) | Comparability (0–2) | Exposure/outcome (0–3) | Total score (max 9) |
|---|---|---|---|---|
| Ben-Dor, 2011 [1] | 3 – Clear TAVR cohort, well-defined PH and outcomes | 1 – Adjusted for major confounders (age, EF) | 2 – Outcome data from registry follow-up | 6/9 |
| Boxhammer, 2024 [11] | 4 – Comprehensive systematic selection per PRISMA | 2 – High comparability across included studies | 3 – Detailed exposure definitions and synthesis | 9/9 |
| Miyamoto, 2022 [10] | 3 – Clear inclusion (AS + TAVR + PH), defined outcomes | 2 – Multivariate analysis controlling for confounders | 3 – Prospective data with validated measures | 8/9 |
| Schewel, 2015 [4] | 3 – Consecutive TAVR cohort, PH defined echocardiographically and invasively | 2 – Groups balanced for baseline risk | 3 – Robust outcome assessment (RHC validation) | 8/9 |
| D’Ascenzo, 2015 [5] | 3 – Multi-centre registry, clear inclusion/exclusion | 2 – Adjusted for multiple covariates | 3 – Standardised data collection and outcomes | 8/9 |
| Testa, 2016 [6] | 3 – Defined PH subgroups in TAVR patients | 2 – Adjusted for key comorbidities | 2 – Outcome ascertainment moderate quality | 7/9 |
| Bishu, 2014 [7] | 3 – Consecutive TAVR cases, PH defined by ECHO | 1 – Partial adjustment for confounders | 2 – Retrospective but consistent outcomes | 6/9 |
| Luçon, 2014 [2] | 4 – Very large TAVR cohort (n > 2000), robust selection | 2 – Full multivariate modelling | 3 – Validated outcome measures (mortality) | 9/9 |
| Alushi, 2019 [8] | 3 – Prospective invasive cohort, clear PH definition | 2 – Adjusted for baseline characteristics | 3 – Comprehensive follow-up for outcomes | 8/9 |
| Lindman, 2015 [3] | 3 – PARTNER I registry, well-defined PH and outcomes | 2 – Propensity matching for confounders | 3 – Robust outcome assessment | 8/9 |
| Rodés-Cabau, 2010 [9] | 3 – Canadian multicentre, clear inclusion/exclusion | 2 – Adjusted for baseline variables | 2 – Long-term follow-up for mortality | 7/9 |
Table 2
ROBIS quality assessment (systematic reviews)
| Author, year | Eligibility criteria | Search and selection | Data handling | Synthesis and reporting | Overall judgement |
|---|---|---|---|---|---|
| Khalil, 2024 [12] | Adults with severe AS undergoing TAVR; PH status and mortality outcomes clearly defined | PRISMA-based, multiple databases (PubMed, Embase, Cochrane, WoS), dual screening | Dual extraction, NOS used | Random-effects meta-analysis; sensitivity and subgroup analyses; transparent reporting | Low risk/high quality |
| Tang, 2017 [13] | Clear inclusion: TAVR, PH-assessed, mortality outcomes reported | PRISMA-guided, 2 independent reviewers, comprehensive database search | Data extracted systematically; NOS used | Random-effects model, meta-regression, publication bias (EGGER/ BEGG). | Low risk/high quality |
| Desai, 2023 [14] | Clear inclusion: TAVR + PH studies ≥100 pts. excluded poor-quality studies | PRISMA-based multi-database search, dual screening | Structured data extraction and NOS quality grading | Narrative synthesis (heterogeneity prevented pooling) | Moderate quality/some concerns |
| Meybodi, 2024 [15] | Included TAVR studies with PH data and outcomes; excluded duplicates/overlaps | Comprehensive multi-database search (PubMed, Embase, Scopus, Cochrane, ProQuest), predefined strategy | Extracted ORS, meta-regression to test covariates; publication bias tested (EGGER, Begg) | Pooled 33 studies, random-effects model, heterogeneity and sensitivity analysis described | Low risk/high quality |
| Boxhammer, 2022 | Severe AS + PH, focus on non-invasive diagnostics; English-only inclusion | Systematic PubMed Central® search with explicit search terms and PRISMA flow | Abstract + full-text screening, duplicate removal; descriptive data extraction | Narrative synthesis across 39 studies (echo, CT/MRI, biomarkers) | Moderate quality/some concerns (narrative only) |
| Kokkinidis, 2018 | Severe as undergoing TAVR; studies reporting PH and mortality | Systematic search; inclusion criteria clear | Data pooled appropriately, risk of bias discussed | Random-effects meta-analysis, sensitivity/ subgroup analyses | Moderate-high quality |
Table 3
ROBIS summary (low-to-moderate overall risk)
| Author, year | Type | Inclusion criteria | No. of studies | PH definition | Main findings | Quality tool | Overall judgement |
|---|---|---|---|---|---|---|---|
| Khalil, 2024 [12] | Systematic review + meta-analysis | Severe AS + TAVI, PH & mortality reported | 15 | Echo or RHC | Pooled PH ↑ mortality | ROBIS | Low risk/high quality |
| Tang, 2017 [13] | Systematic review + meta-analysis | TAVI, PH assessed, mortality outcomes | 11 | Per study | PH increased mortality | ROBIS | Low risk/high quality |
| Desai, 2023 [14] | Systematic review | ≥100 pts, TAVI + PH | 10 | Various | Narrative synthesis only | ROBIS | Moderate/some concerns |
| Meybodi, 2024 [15] | Systematic review + meta-analysis | TAVI + PH data | 33 | Various | Pooled analysis confirms risk | ROBIS | Low risk/high quality |
| Boxhammer, 2022 | Systematic review (diagnostic) | Severe AS + PH (non-invasive) | 39 | Echo, CT, MRI | PH diagnosis methods heterogeneous | ROBIS | Moderate/some concerns |
| Kokkinidis, 2018 | Systematic review + meta-analysis | Severe as undergoing TAVI | 20 | Echo-based | PH associated with mortality | ROBIS | Moderate–high quality |
Table 4
Characteristics of observational studies.
| Author, year | Population/design | N | PH definition | Mean age (years) | Ejection fraction (%) | 1-year mortality (%) | Key findings |
|---|---|---|---|---|---|---|---|
| Ben-Dor, 2011 [1] | Single-centre TAVI registry | 509 | sPAP ≥ 40 mmHg (echo) | 81.7 | 47.5 | 44.0 | PH independently predicted mortality |
| Boxhammer, 2024 [11] | Single-centre, sex-stratified | 303 | sPAP threshold per study | 82.6 | 55 | 17.2 | Higher risk signal; sex interaction |
| Miyamoto, 2022 [10] | OCEAN-TAVI (multicentre) | 1,872 | sPAP > 36 mmHg (echo) | 84.7 | 58.5 | 15.9 | Residual/new-onset PH ↑ mortality |
| Schewel, 2015 [4] | Single-centre (Hamburg) | 559 | mPAP ≥ 25 mmHg (RHC) | 79.8 | 49.5 | 23.4 | Invasive PH remained an independent predictor |
| D’Ascenzo, 2015 [5] | Multicentre (Italy) | 674 | sPAP > 40 mmHg (echo) | 81.5 ± 5.6 | 51 ± 11.6 | 31.0 | Persistent PH strongest predictor |
| Testa, 2016 [6] | CoreValve multicentre registry | 900 | sPAP > 60 mmHg | 79.5 | 50 | 11.6 | Severe PH predicts 1-year mortality |
| Bishu, 2014 [7] | Single-centre (Mayo Clinic) | 277 | PASP tertiles (≥49 mmHg) | 81 ± 8 | 53 ± 15 | 35.0 | Highest tertile → highest mortality |
| Luçon, 2014 [2] | FRANCE-2 (national) | 2435 | sPAP ≥ 40/ ≥ 60 mmHg | 83 ± 7 | 49 ± 15 | 28.0 | PH independently predicted mortality |
| Alushi, 2019 [8] | Prospective invasive cohort | 617 | Echo/RHC PH | 80 ± 8 | 56 ± 4 | 27.0 | Invasive PH and RV parameters predictive |
| Lindman, 2015 [3] | PARTNER I registry | 2180 | mPAP ≥ 25 (mod/sev ≥ 35) | 83 ± 8 | 55 | 25.0 | PH predicted mortality – - esp. in women |
| Rodés-Cabau, 2010 [9] | Canadian multicentre | 339 | sPAP > 60 mmHg | 81 ± 8 | 55 ± 14 | 22.1 | PH associated with late mortality |
Figure 2
Overall 1-year mortality forest plot. CI, confidence interval.
Figure 3
High-quality studies (NOS ≥ 8). CI, confidence interval; NOS, Newcastle–Ottawa Scale.
Figure 4
Moderate-quality studies (NOS 6–7). CI, confidence interval; NOS, Newcastle–Ottawa Scale.