Patient case-mix for TAVR has evolved to include more low-risk candidates since the 2019 indication expansion, and younger patients, while more likely to be classified as low-risk, exhibit increased one-year mortality after risk adjustment, according to a Brief Report recently published in JACC.

Sondos Alabbadi, PharmD, PhD, et al., analyzed 583,215 patients undergoing TAVR to treat aortic stenosis from 2012 to 2024, captured by the STS/ACC TVT Registry. Of note, 5% of patients were younger than 65-years-old. The investigators compared case-mix and 30-day outcomes both before and after the indication expansion for TAVR in 2019 and explored one-year outcomes using adjusted models.

Overall, they found that the number of sites performing TAVR in patients younger than 65 years increased from 161 to 726, low-risk cases increased from 2.7% to 35.7%, and the rate of bicuspid aortic valve prevalence rose from 15.7% to 24.1%.

Evaluating 30-day outcomes, mortality, readmission, reintervention, stroke and endocarditis rates were all similar in older patients vs. those under the age of 65.

At one year post TAVR, among patients younger than 65 years, every five-year increase in age saw a 10% decrease in mortality (adjusted hazard ratio 0.90 [95% CI 0.87-0.92]), this association remained significant even after excluding patients with major comorbidities. Meanwhile, patients above 65 years saw a 15% increase in mortality for every five-year increase in age.

“The risk-adjusted inverse age-mortality relationship in patients younger than 65 years reflects phenotypic heterogeneity: ‘very young’ patients often exhibit extreme-risk, noncalcific phenotypes, whereas those approaching 65 years resemble standard degenerative cases,” write the authors. “This association likely reflects residual confounding from unmeasured noncardiac frailty or socioeconomic disadvantages.”