Guidelines Versus Practice: Surgical Versus Transcatheter Aortic Valve Replacement in Adults < 60 Years

Abstract

Consensus guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis aged < 65 years. This analysis evaluates clinical practice and outcomes of TAVR and SAVR in patients < 60 years. We identified 2,360 patients aged < 60 years including 523 TAVR (22.2%) and 1,837 SAVR (77.8%) procedures from 2013-2021 using the California Department of Health Care Access and Information database. The median follow-up time was 2.4 (IQR:1.1-4.5) years after TAVR and 4.9 (IQR:2.8-6.9) years after SAVR. The primary outcome was 5-year survival. Secondary outcomes included cumulative incidences of reoperation, endocarditis, stroke, and heart failure readmissions with death as a competing risk, compared using propensity score matching. Between 2013 and 2021 TAVR rates in patients aged < 60 years increased from 7.2% to 45.7% (annual increase of 4.7%, p<0.001). Thirty-day mortality was similar for SAVR and TAVR (0.2% vs. 0.4% (p=0.20). In 358 propensity-matched pairs, TAVR was associated with an increased hazard of 5-year mortality (HR 2.5, 95% CI 1.1-3.7, p=0.02). There was no significant difference in the cumulative incidences of reoperation (2.2% vs. 3.8%, p=0.25), stroke (1.1% vs. 0.8%, p=0.39), endocarditis (0.8% vs. 0.4%, p=0.38), and heart failure readmission (1.9% vs. 1.2%, p=0.10). TAVR use approaches SAVR use in patients aged < 60 years in California and is associated with significantly worse 5-year survival. This may indicate a need for randomized trials to inform best practice recommendations.