Trends in TAVR and SAVR Among Older US Adults

Quick Takes

  • Within a decade after the advent of TAVR, the number of older adults undergoing AVR increased by almost 60%, whereas the patient age remained similar with a slightly increasing comorbidity profile.
  • Furthermore, this was accompanied by decreasing mortality, readmission, and non–home discharge rates.
  • Given the rapid evolution of TAVR and declining SAVR volume, there is a need for ongoing monitoring to ensure both SAVR and TAVR remain safe treatment options for older adults with aortic stenosis.

Study Questions:

What are the trends in characteristics and outcomes of patients undergoing transcatheter (TAVR) and surgical aortic valve replacement (SAVR) in the United States?

Methods:

The investigators analyzed Medicare beneficiaries who underwent TAVR and SAVR from 2012–2019. They evaluated case volume, demographics, comorbidities, 1-year mortality, and discharge disposition. The outcomes were 30-day, 6-month, and 1-year all-cause mortality defined as death occurring within the respective time frame from the index hospitalization for an AVR. The authors also evaluated 30-day readmission, defined as all-cause rehospitalization within 30 days after the index hospitalization. Cox proportional hazard models were used to assess the annual change in outcomes.

Results:

Per 100,000 beneficiary-years, AVR increased from 107 to 156, TAVR increased from 19 to 101, whereas SAVR declined from 88 to 54. The median [interquartile range] age remained similar from 77 [71-83] years to 78 [72-84] years for overall AVR, decreased from 84 [79-88] years to 81 [75-86] years for TAVR, and decreased from 76 [71-81] years to 72 [68-77] years for SAVR. For all AVR patients, the prevalence of comorbidities remained relatively stable. The 1-year mortality for all AVR decreased from 11.9% to 9.4%. Annual change in the adjusted odds of 1-year mortality was 0.93 (95% confidence interval [CI], 0.92-0.94) for TAVR and 0.98 (95% CI, 0.97-0.99) for SAVR, and 0.94 (95% CI, 0.93-0.95) for all AVR. Patients discharged to home after AVR increased from 24.2% to 54.7%, primarily driven by increasing home discharge after TAVR.

Conclusions:

The authors concluded that the advent of TAVR has led to about a 60% increase in overall AVR in older adults.

Perspective:

This study reports that within a decade after the advent of TAVR, the number of older adults undergoing AVR increased by almost 60%, whereas the patient age remained similar with a slightly increasing comorbidity profile. Furthermore, this was accompanied by decreasing mortality, readmission, and non–home discharge rates. It is reassuring that increasing TAVR volume in patients with a lower-risk profile did not appear to worsen SAVR outcomes, and the overall AVR outcomes continued to improve. Given the rapid evolution of TAVR and declining SAVR volume, there is a need for ongoing monitoring to ensure both SAVR and TAVR remain safe treatment options for older adults with aortic stenosis.

Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Comorbidity, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Patient Discharge, Patient Readmission, Primary Prevention, Transcatheter Aortic Valve Replacement


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