Alabbadi Sundos, Malas Jad, Chen Qiudong, Cheng Wen, Tam Derrick Y, Cohen Robbin G, Bowdish Michael E, Egorova Natalia, Chikwe Joanna
Department of Population Health Science and Policy at Icahn School of Medicine at Mount Sinai, New York, New York.
Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, California.
Ann Thorac Surg. 2025 Apr;119(4):861-869. doi: 10.1016/j.athoracsur.2024.07.036. Epub 2024 Aug 22.
Consensus guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis aged ≤65 years. This analysis evaluates clinical practice and outcomes of TAVR and SAVR in patients aged ≤60 years.
We identified 2360 patients aged ≤60 years, including 523 TAVR (22.2%) and 1837 SAVR (77.8%) procedures, from 2013 through 2021 using the California Department of Health Care Access and Information database. The median follow-up time was 2.4 years (interquartile range, 1.1-4.5 years) after TAVR and 4.9 years (interquartile range, 2.8-6.9 years) after SAVR. The primary outcome was 5-year survival. Secondary outcomes included cumulative incidences of reoperation, endocarditis, stroke, and heart failure readmissions with death as a competing risk, compared using propensity score matching.
Between 2013 and 2021 TAVR rates in patients aged ≤60 years increased from 7.2% to 45.7% (annual increase of 4.7%, P < .001). Mortality at 30 days was similar for SAVR and TAVR (0.2% vs 0.4%, P = .20). In 358 propensity-matched pairs, TAVR was associated with an increased hazard of 5-year mortality (hazard ratio, 2.5; 95% CI, 1.1-3.7; P = .02). There was no significant difference in the cumulative incidences of reoperation (2.2% vs 3.8%, P = .25), stroke (1.1% vs 0.8%, P = .39), endocarditis (0.8% vs 0.4%, P = .38), and heart failure readmission (1.9% vs 1.2%, P = .10).
TAVR use approaches SAVR use in patients aged ≤60 years in California and is associated with significantly worse 5-year survival. This may indicate a need for randomized trials to inform best practice recommendations.
共识指南推荐，对于年龄≤65岁的重度主动脉瓣狭窄患者，应进行外科主动脉瓣置换术（SAVR）而非经导管主动脉瓣置换术（TAVR）。本分析评估了年龄≤60岁患者接受TAVR和SAVR的临床实践及结局。
我们利用加利福尼亚医疗保健获取与信息部数据库，确定了2013年至2021年间2360例年龄≤60岁的患者，其中包括523例（22.2%）TAVR手术和1837例（77.8%）SAVR手术。TAVR术后的中位随访时间为2.4年（四分位间距，1.1 - 4.5年），SAVR术后为4.9年（四分位间距，2.8 - 6.9年）。主要结局为5年生存率。次要结局包括再次手术、心内膜炎、中风以及因心力衰竭再次入院的累积发生率，并将死亡作为竞争风险，采用倾向评分匹配进行比较。
2013年至2021年间，年龄≤60岁患者的TAVR使用率从7.2%增至45.7%（年增长率4.7%，P <.001）。SAVR和TAVR的30天死亡率相似（0.2%对0.4%，P =.20）。在358对倾向评分匹配的病例中，TAVR与5年死亡风险增加相关（风险比，2.5；95%可信区间，1.1 - 3.7；P =.02）。再次手术（2.2%对3.8%，P =.25）、中风（1.1%对0.8%，P =.39）、心内膜炎（0.8%对0.4%，P =.38）以及心力衰竭再次入院（1.9%对1.2%，P =.10）的累积发生率无显著差异。
在加利福尼亚州，年龄≤60岁患者中TAVR的使用情况接近SAVR，但TAVR与5年生存率显著较差相关。这可能表明需要进行随机试验以提供最佳实践建议。
