Temporal Trends in Transcatheter Aortic Valve Replacement for Isolated Severe Aortic Stenosis

How to avoid transcatheter aortic valve replacement explant as the second valve procedure: image assessment for the index transcatheter aortic valve replacement

The management of severe aortic stenosis (AS) has evolved significantly, with a shift toward shared decision-making regarding the choice of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). This shift necessitates careful consideration of long-term valve durability, as both TAVR and SAVR with bioprosthetic valves offer limited durability, potentially requiring reoperation later in life. While mechanical valves and the Ross procedure offer lifelong durability, patient preferences, including avoidance of anticoagulation, often dominate the discussion. This manuscript reviews the complex decision-making process in selecting the most appropriate valve for the first intervention, focusing on balancing the immediate benefits of a less invasive procedure with the long-term risks and the potential need for a second valve intervention. In the TAVR era, younger patients elect the least invasive treatment option with the shortest recovery. Age, anticoagulation tolerance, comorbidities, and aortic root anatomy influence valve choice, with particular attention to prosthesis-patient mismatch (PPM). Here, we emphasize that careful preoperative planning is essential to minimize PPM and optimize hemodynamics for the first valve, considering the possibility of future valve interventions. Furthermore, advanced imaging and simulation tools, such as computed tomography (CT) and artificial intelligence-based platforms, are now being utilized to predict the feasibility of redo interventions and guide the selection of the initial valve. The increasing prevalence of redo-TAVR and TAVR explantation underscores the importance of planning for a second valve at the time of the initial intervention. Simulation techniques can predict the anatomical feasibility of redo-TAVR, providing a safer framework for managing patients requiring subsequent valve replacements. Ultimately, heart teams must equip themselves with the tools and expertise necessary to ensure the durability of the first valve and readiness for future interventions, thereby improving patient outcomes over their lifetimes.

Outcomes of Balloon-Expandable Transcatheter Aortic Valve Replacement in Younger Patients in the Low-Risk Era

Importance

Guidelines advise heart team assessment for all patients with aortic stenosis, with surgical aortic valve replacement recommended for patients younger than 65 years or with a life expectancy greater than 20 years. If bioprosthetic valves are selected, repeat procedures may be needed given limited durability of tissue valves; however, younger patients with aortic stenosis may have major comorbidities that can limit life expectancy, impacting decision-making.

Objective

To characterize patients younger than 65 years who received transcatheter aortic valve replacement (TAVR) and compare their outcomes with patients aged 65 to 80 years.

Design, Setting, and Participants

This retrospective registry-based analysis used data on 139 695 patients from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (TVT) Registry, inclusive of patients 80 years and younger undergoing TAVR from August 2019 to September 2023.

Intervention

Balloon-expandable valve (BEV) TAVR with the SAPIEN family of devices.

Main Outcomes and Measures

Comorbidities (heart failure, coronary artery disease, dialysis, and others) and outcomes (death, stroke, and hospital readmission) of patients younger than 65 years compared to patients aged 65 to 80 years.

Results

In the years surveyed, 13 849 registry patients (5.7%) were younger than 65 years, 125 846 (52.1%) were aged 65 to 80 years, and 101 725 (42.1%) were 80 years and older. Among those younger than 65, the mean (SD) age was 59.7 (4.8) years, and 9068 of 13 849 patients (65.5%) were male. Among those aged 65 to 80 years, the mean (SD) age was 74.1 (4.2) years, and 77 817 of 125 843 patients (61.8%) were male. Those younger than 65 years were more likely to have a bicuspid aortic valve than those aged 65 to 80 years (3472/13 755 [25.2%] vs 9552/125 001 [7.6%], respectively; P < .001). They were more likely to have congestive heart failure, chronic lung disease, diabetes, immunocompromise, and end stage kidney disease receiving dialysis. Patients younger than 65 years had worse baseline quality of life (mean [SD] Kansas City Cardiomyopathy Questionnaire score, 47.7 [26.3] vs 52.9 [25.8], respectively; P < .001) and mean (SD) gait speed (5-meter walk test, 6.6 [5.8] seconds vs 7.0 [4.9] seconds, respectively; P < .001) than those aged 65 to 80 years. At 1 year, patients younger than 65 years had significantly higher readmission rates (2740 [28.2%] vs 23 178 [26.1%]; P < .001) and all-cause mortality (908 [9.9%] vs 6877 [8.2%]; P < .001) than older patients. When propensity matched, younger patients still had higher 1-year readmission rates (2732 [28.2%] vs 2589 [26.8%]; P < .03) with similar mortality to their older counterparts (905 [9.9%] vs 827 [10.1%]; P = .55).

Conclusions and Relevance

Among US patients receiving BEV TAVR for severe aortic stenosis in the low-surgical risk era, those younger than 65 years represent a small subset. Patients younger than 65 years had a high burden of comorbidities and incurred higher rates of death and readmission at 1 year compared to their older counterparts. These observations suggest that heart team decision-making regarding TAVR for most patients in this age group is clinically valid.

Transcatheter Aortic Valve Replacement: Latest Advances and Prospects

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