Transcatheter versus surgical aortic valve replacement in patients younger than 65 years in the United States.

OBJECTIVE

The study objective was to characterize the trends and outcomes of aortic valve replacement in patients aged less than 65 years with aortic stenosis between 2013 and 2021.

METHODS

This retrospective analysis included 9557 patients who underwent biological aortic valve replacement in California, New York, and New Jersey from 2013 to 2021. Patients were stratified by approach: transcatheter aortic valve replacement versus surgical aortic valve replacement. Our primary outcomes were 30-day and 6-year mortality and morbidity (stroke, heart failure rehospitalization, reintervention, and new pacemaker implantation). After propensity score matching, Cox proportional hazard and Fine-Gray models were used to compare outcomes after transcatheter aortic valve replacement and surgical aortic valve replacement.

RESULTS

The proportion of patients aged less than 65 years with aortic stenosis undergoing transcatheter aortic valve replacement versus surgical aortic valve replacement increased from 7.1% in 2013 to 54.7% in 2021. After propensity score matching, 30-day mortality was similar between both groups (1.0% vs 1.5%, P = .33). Transcatheter aortic valve replacement had a higher 6-year mortality (23.3% vs 10.5%, hazard ratio, 2.27; 95% CI, 1.82-2.83; P < .001). The 30-day rate of new pacemaker implantation was higher after transcatheter aortic valve replacement (10.7% vs 6.2%, P < .001). There was no difference in the 6-year cumulative incidence of stroke, heart failure hospitalizations, or reoperations. Multiple sensitivity analyses confirmed these findings.

CONCLUSIONS

Despite clinical guidelines, the use of transcatheter aortic valve replacement has increased in patients aged less than 65 years. Transcatheter aortic valve replacement in this population is associated with a higher 6-year mortality and a higher rate of new permanent pacemaker implantation when compared with a matched cohort treated with biologic surgical aortic valve replacement. These findings support the need for a randomized controlled trial comparing long-term outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients aged less than 65 years.