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National Trends in TAVR and SAVR for Severe Aortic Stenosis
Quick Takes
- There has been dramatic growth of TAVR in all age groups including among young patients in recent years.
- While SAVR is recommended by AHA/ACC guidelines for patients <65 years old with severe aortic stenosis, there was near equal utilization between TAVR and SAVR in these younger patients by 2021.
- Additional studies are indicated in young patients with severe aortic stenosis undergoing TAVR including issues related to lifetime coronary access, valve durability, and the potential for redo TAVR procedures over time.
Study Questions:
What are the temporal trends in transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in different age groups among patients with severe aortic stenosis (AS)?
Methods:
The investigators identified patients who underwent TAVR or SAVR from October 1, 2015–December 31, 2021 (n = 279,066) using the Vizient® Clinical Data Base. They excluded patients with indications for surgery other than isolated AS, leading to a final national cohort of 142,953 patients. The authors compared temporal trends according to the three guideline-recommended age groups that influence strategy: age <65, 65-80, and >80 years old. Independent predictors of TAVR in the <65 year old age group were identified using multivariable logistic regression based on univariate predictors (p < 0.10) identified from baseline clinical variables.
Results:
TAVR utilization doubled during the study period: 2015–2016, 44.9% vs. 2021, 88%, p < 0.01 for temporal trend. AS patients <65 years old comprised 12.2% (n = 17,487) of the total study population. In patients <65 years old, TAVR utilization increased 2.7-fold during the study period, reaching nearly equal volumes as SAVR by 2021 (47.5% TAVR vs. 52.5% SAVR, p = not significant). Notably, the relative increase in TAVR over time was greater among patients <65 years old as compared to the other two age groups. For patients aged >80 years old, TAVR remained the preferred treatment modality throughout the study period, with utilization rate exceeding 98% by 2021. The most powerful independent predictors of TAVR in young patients were congestive heart failure (odds ratio [OR], 3.84; 95% confidence interval [CI], 3.56-4.13; p < 0.0001), prior coronary artery bypass grafting (OR, 3.49; 95% CI, 2.98-4.08; p < 0.001), and absence of bicuspid aortic valve disease (OR, 0.20; 95% CI, 0.17-0.23; p < 0.001).
Conclusions:
The authors reported dramatic growth of TAVR in all age groups including young patients.
Perspective:
This database study demonstrates the dramatic growth of TAVR in all age groups including among young patients. While SAVR is recommended by 2020 American Heart Association/American College of Cardiology (AHA/ACC) guidelines for patients <65 years old with severe AS, there was near equal utilization between TAVR and SAVR in these younger patients by 2021. These observations have significant ramifications for lifetime management strategies in young patients with severe AS, including issues related to lifetime coronary access, valve durability, and the potential for redo TAVR procedures over time, and needs additional study.
Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Interventions, Acute Heart Failure, Interventions and Structural Heart Disease
Keywords: Aged, 80 and over, Aortic Valve Stenosis, Bicuspid Aortic Valve Disease, Cardiac Surgical Procedures, Coronary Artery Bypass, Geriatrics, Heart Failure, Heart Valve Diseases, Secondary Prevention, TCT22, Transcatheter Aortic Valve Replacement, Transcatheter Cardiovascular Therapeutics
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