55. Transcatheter versus Surgical Aortic Valve Replacement in US Patients Younger than 65 Years of Age

Objective: The 2020 ACC/AHA guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS) in patients <65 years. We compare trends and outcomes of TAVR and SAVR in patients <65 years of age in the United States.
Methods: All-payer mandatory discharge datasets for California, New Jersey, and New York states were used to identify 9,886 patients age <65 years from 185 hospitals between 2013 to 2021. Of these, 2,566 (26%) had TAVR, and 7,316 (74%) had SAVR. The primary outcome was survival. Secondary outcomes included reoperation, stroke, readmission with heart failure (HF), and new permanent pacemakers. The primary and secondary outcomes were compared at 8 years after propensity score matching in a Cox-proportional hazard model and Fine-Gray models respectively. Median follow-up was 4.1 years (IQR: 2.1-6.4 years).
Results: The proportion of patients age <65 years undergoing TAVR increased from 7% in 2013 to 55% in 2021 (p<0.001). After matching, 30-day mortality was similar (1.3 vs. 0.9%, p=0.26) and new permanent pacemaker implantations were higher after TAVR (10.9% vs. 5.7%, p<0.001). The 8-year mortality was higher after TAVR (25 vs. 11.5%, HR: 2.50 [1.95-3.20], p<0.001, Figure A). There were no differences in the 8-year risk of readmission with heart failure (HR: 1.40 [0.87-2.25], p=0.24) or stroke (HR:1.64 [0.79-3.37], p=0.20). The risk of reoperation was higher at 2 years for TAVR (Figure 1B - HR:3.37 [1.53-7.44], p=0.003), but similar between TAVR and SAVR after 2 years (HR:0.69 [0.45-1.71], p=0.69). In a sensitivity analysis limited to patients from 2019-2021, mortality remained higher after TAVR (HR: 2.83 [1.68-4.79], p<0.001).
Conclusion: TAVR now represents the majority of aortic valve replacements in patients <65 years despite current consensus guideline recommendations. Superior mid-term survival after SAVR reinforces current consensus guidelines and supports the need for long-term follow-up data from low-risk clinical trials.

Sundos Alabbadi (1), Derrick Tam (2), Irsa Hassan (2), Aminah Sallam (3), Michael Bowdish (4), Joanna Chikwe (5), natalia egorova (6), (1) Icahn School of Medicine at Mount Sinai, New York, New York, (2) Cedars-Sinai Medical Center, Los Angeles, CA, (3) Cedars Sinai Medical Center, Los Angeles, CA, (4) Cedars-Sinai Medical Center, La Canada, CA, (5) Cedars-Sinai Medical Center, Beverly Hills, CA, (6) Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, New York, NY

Michael Bowdish

Abstract Presenter

Dr. Bowdish serves as Professor and Vice Chair of the Department of Cardiac Surgery at the Smidt Heart Institute, Cedars-Sinai Medical Center. Dr. Bowdish’s clinical expertise focuses on aortic surgery, including aortic root reconstruction, valve-sparing root surgery, aortic arch surgery, hybrid repair techniques, in addition to heart transplantation, and mechanical circulatory support. Dr. Bowdish’s research focuses on pivotal randomized trials in cardiac surgery primarily through the NIH-sponsored Cardiothoracic Surgical Trials Network. Dr. Bowdish’s currently serves as Chair of the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database Task Force.