Research presented at the 60th annual meeting of the Society of Thoracic Surgeons (STS 2024; 27–29 January, San Antonio, USA) shows a shift in the proportion of patients aged under 60 years with severe aortic stenosis, eligible for surgical aortic valve replacement (SAVR), who are receiving transcatheter aortic valve implantation (TAVI).
Using data from California spanning 2013 to 2021 researchers from the department of cardiac surgery in the Smidt Heart Institute at Cedars-Sinai in Los Angeles and the department of population health science and policy at Mount Sinai New York compared outcomes for patients undergoing surgery and those undergoing TAVI.
From a pool of 37,011 patients, the study identified 2,360 patients under the age of 60 years who underwent these procedures, with 22% receiving TAVI and 78% SAVR. By 2021 almost half of patients younger than 60 years were receiving TAVI rather than SAVR. The research team followed these patients for a median time of 2.4 years after TAVI and 4.9 years after SAVR to assess their outcomes.
The primary focus was on five-year survival rates. Secondary outcomes included rates of reoperation, infective endocarditis, stroke, and hospital admissions for heart failure. Propensity score matching ensured a fair comparison of 358 pairs of patients, balancing factors such as age, major health conditions, hospital volume, and urgency.
The researchers report that the 30-day mortality rates were similar (0.2% for SAVR vs. 0.4% for TAVI), but found that the five-year survival rate was better after surgery compared to TAVI (98% vs. 86%, p<0.001). For secondary outcomes, there was no significant difference between the two groups.
“While we expected that the volume of transcatheter therapy would increase over the study period in this young patient cohort, we were surprised there appears to be near equipoise in terms of procedure selection, with patients and clinicians opting for procedures against the 2020 guidelines,” said study co-author Jad Malas (Cedars-Sinai Medical Center, Los Angeles, USA).
In their 2020 consensus guidelines, the American College of Cardiology (ACC) and the American Heart Association (AHA) recommended surgery over TAVR in patients under 65 with severe aortic stenosis. Malas and colleagues wanted a real-world snapshot of how hospitals are treating patients in an even younger cohort.
The study results indicate a need for randomised trials in younger patients—as well as more balanced and informed patient-centred decision-making—to support more appropriate practice in this younger patient population, said Joanna Chikwe, senior author of the study and chair of the department of cardiac surgery in the Smidt Heart Institute at Cedars-Sinai (Los Angeles, USA). She added that her research group has expanded their analysis to include a multi-state registry for better comparison of the two procedures.
“As cardiac surgeons, we owe it to our patients to take a more prominent role in providing the highest quality evidence to help our patients make these major healthcare decisions,” she emphasised. “While transcatheter therapy appears more attractive to most patients, there are clearly long-term benefits with surgical therapy for the lifetime management of valvular heart disease in many patients.”
