More younger patients opt for TAVR vs. surgery, despite poorer outcomes
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Key takeaways:
- Transcatheter aortic valve replacement for younger adults with severe aortic stenosis rose nearly ninefold from 2013 to 2021.
- Younger patients had poorer 5-year survival rates with TAVR vs. surgical AVR.
Adults younger than 60 years with severe aortic stenosis are increasingly opting for transcatheter aortic valve replacement despite data suggesting poorer 5-year survival compared with surgical AVR, researchers reported.
The data were presented at the Society of Thoracic Surgeons Annual Meeting in San Antonio.
The 2020 American College of Cardiology/American Heart Association consensus guidelines recommend surgical AVR (SAVR) for adults younger than 65 years with severe aortic stenosis. Yet, data are lacking on long-term outcomes for adults aged 60 years or younger with severe aortic stenosis who opt for TAVR over SAVR, according to Joanna Chikwe, MD, FRCS, founding chair of the department of cardiac surgery in the Smidt Heart Institute at Cedars-Sinai and the Irina and George Schaeffer Distinguished Chair in Cardiac Surgery.
“We knew that the recently released 4- and 5-year results of the low-risk Partner and Evolut trials would focus more attention on the best choice for younger patients,” Chikwe told Healio. “But, neither trial addressed this question, as fewer than 10% of patients included were younger than 60 years. We designed this study specifically to understand the implications of TAVR vs. SAVR choice among younger patients.”
Registry data for younger adults
Chikwe and colleagues analyzed data from 2,360 adults younger than 60 years who underwent TAVR (n = 523) or SAVR (n = 1,837) from 2013 to 2021 in California, using the Department of Health Care Access and Information database. Median follow-up time was 2.4 years after TAVR and 4.9 years after SAVR. The primary outcome was 5-year survival. Secondary outcomes included cumulative incidence of reoperation, infective endocarditis, stroke and readmission with HF assessed at 30 days and 5 years.
The researchers also used propensity-score matching for 31 patient characteristics, including age, major comorbidity, hospital volume and urgency, for 358 balanced patient pairs to compare TAVR with SAVR, and also calculated the annual percent change in rate to assess practice trends.
“Before we started the study, most clinicians assumed very few young patients were having TAVR; however, that was not our experience,” Chikwe told Healio. “This study confirmed a major shift in practice toward TAVR, even among younger patients in California. We are seeing the same shift in data from other states. Early in the study, these younger TAVR patients had a lot of major comorbidities like dialysis, cancer, strokes and immobility, so TAVR was likely a safer option for them than SAVR. But later in the study, as TAVR rates in this age group approach 50% without much overall increase in the total pool of patients having aortic valve replacement, the TAVR patients seem much lower risk. We wonder if patients simply prefer a much less invasive option, especially if there are no compelling data on long-term implications.”
From 2013 to 2021, the rate of TAVR for patients younger than 60 years increased from 7% 2013 to 62% in 2021, for an annual percent change of 4.7% (P < .001).
Researchers found 30-day mortality rates for SAVR vs. TAVR were 0.2% and 0.4%, respectively (P = .2), with a significant advantage in survival rate for SAVR vs. TAVR at 5 years (98% vs. 86%; P < .001). At 5 years, there were no significant between-group differences for incidence of reoperation, stroke, infective endocarditis and HF readmission.
In propensity-matched patients, the 5-year survival rate was better after SAVR (93% vs. 88%), for an HR of 2.5 favoring SAVR (95% CI, 1.1-3.7; P = .02). There was no difference in the cumulative incidence of secondary outcomes in the matched cohort.
More hospitals going against guidance
Additionally, of 97 hospitals across California offering TAVR, 69.1% performed the procedure for adults younger than 60 years. There were no differences in median surgical volume across hospitals that did and did not perform TAVR for younger patients (P = .73), according to researchers.
“These data tells us that clinical practice is increasingly not guideline-concordant and younger patients may have better midterm survival with SAVR,” Chikwe told Healio. “The findings reflect the likelihood that the TAVR cohort were sicker patients even after adjusting for comorbidities and frailty. A randomized trial could address this major limitation of these types of studies, and our data suggest there may be enough clinical and patient equipoise to support that. Our clinical practice has certainly shifted to focusing on the lifetime management of aortic valve disease among younger patients, including more frequent use of the Ross procedure to minimize the need for reintervention and anticoagulation. Nonthrombogenic, durable prosthetic valves are the holy grail for this important patient population.”
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Alabbadi S, et al. Guidelines versus practice: A statewide survival analysis of SAVR versus TAVR in patients aged < 60 years. Presented at: Society of Thoracic Surgeons Annual Meeting; Jan. 27-29, 2024; San Antonio.
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