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Trends in the Use of Isolated Surgical and Transcatheter Aortic Valve Replacement in Patients Younger Than 70 Years of Age

      To The Editor:
      The demonstrated safety and efficacy of transcatheter aortic valve replacement (TAVR) in low-risk patients led to its growing acceptance as a standard therapy for aortic stenosis (AS), regardless of patients' surgical risks.
      • Alkhouli M.
      • Alqahtani F.
      • Ziada K.M.
      • Aljohani S.
      • Holmes D.R.
      • Mathew V.
      Contemporary trends in the management of aortic stenosis in the USA.
      However, concerns arose on expanding TAVR to younger patients (<70 years of age), considering the scarce long-term data in this age group and the remaining questions of transcatheter valve durability, coronary reaccess, impact of long-term permanent pacing, and the risk of future surgical aortic valve replacement (SAVR).
      • Jawitz O.K.
      • Gulack B.C.
      • Grau-Sepulveda M.V.
      • et al.
      Reoperation after transcatheter aortic valve replacement: an analysis of the Society of Thoracic Surgeons Database.
      • Rogers T.
      • Greenspun B.C.
      • Weissman G.
      • et al.
      Feasibility of coronary access and aortic valve reintervention in low-risk TAVR patients.
      • Alkhouli M.
      The unrelenting search for bioprosthetic aortic valve durability.
      • Chamandi C.
      • Barbanti M.
      • Munoz-Garcia A.
      • et al.
      Long-term outcomes in patients with new permanent pacemaker implantation following transcatheter aortic valve replacement.
      In this focused analysis, we examined contemporary utilization trends and in-hospital mortality of AVR in patients aged <70 years.
      The Vizient Clinical Data Base (CDB) (Vizient Inc., Irving, Texas) was queried to select patients who underwent isolated SAVR or TAVR between 2012 and 2019, using International Classification of Diseases (ICD)-9/10-CM codes.
      • Alkhouli M.
      • Alqahtani F.
      • Ziada K.M.
      • Aljohani S.
      • Holmes D.R.
      • Mathew V.
      Contemporary trends in the management of aortic stenosis in the USA.
      The CDB contains deidentified data of 100% of index hospitalizations at >400 US academic centers and their affiliates. The primary end point was the trend in the proportion of TAVR to all AVRs. Secondary end points were trends in unadjusted in-hospital mortality. Trends were assessed using the nonparametric Mann-Kendal method. The study was deemed Institutional Review Board exempt because the study uses publicly available deidentified data.
      A total of 140,104 patients who underwent isolated AVR were identified, of whom 54,174 were <70 years old (45,093 SAVR; 9081 TAVR). The proportion of TAVR to all AVRs in this age group increased from 6.8% in 2012, to 28.2% in 2019 (P trend<.001) (Figure). Patients who underwent TAVR were older (63.0±7.3 vs 56.2±11.6 years; P<.001) and more likely to be women (39.4% vs 28.7%, P<.001). In the TAVR group, transfemoral access was used in 95.2% of patients. In the SAVR group, bioprosthetic valves were used in 71.4%. In-hospital mortality decreased over time with TAVR (5.6% in 2012, to 1.8% in 2019; P trend<.001) but remained stable with SAVR (1.9% in 2012, to 2.0% in 2019, P trend=.06) (Figure).
      Figure thumbnail gr1
      FigureTrends in the utilization and outcomes of isolated aortic valve replacement in patients <70 years of age. A, Trends in use. B, Trends in in-hospital mortality.
      This key finding in this focused analysis is the marked increase in the use of TAVR among patients <70 years of age. Nearly 3 in 10 patients aged <70 who were referred for interventions for isolated severe AS in 2019 received TAVR. It is likely that these trends will continue to grow, considering the recent Food and Drug Administration decision to approve TAVR for suitable patients regardless of estimated surgical risk. Although the continuously improving in-hospital mortality for TAVR in this analysis is reassuring, the increasing trends to offer TAVR in patients younger than 70 years of age warrants additional studies with long-term follow-up. Currently available long-term data are derived from the original pivotal TAVR trials in intermediate- and high-risk patients, in which the mean age was ∼80 years.
      • Jawitz O.K.
      • Gulack B.C.
      • Grau-Sepulveda M.V.
      • et al.
      Reoperation after transcatheter aortic valve replacement: an analysis of the Society of Thoracic Surgeons Database.
      The interpretation of these data also needs to consider the inherent limitation of administrative datasets including potential coding inaccuracies, lack of echocardiographic data, and selection bias. Nonetheless, considering that the purpose of this study is to assess trends in major procedures and in-hospital mortality, those limitations are unlikely to have impact on its results. In conclusion, we document a considerable temporal increase in adoption of TAVR in patients aged <70 years. Long-term follow-up is needed before making TAVR the default strategy in these patients.

      References

        • Alkhouli M.
        • Alqahtani F.
        • Ziada K.M.
        • Aljohani S.
        • Holmes D.R.
        • Mathew V.
        Contemporary trends in the management of aortic stenosis in the USA.
        Eur Heart J. 2020; 41: 921-928
        • Jawitz O.K.
        • Gulack B.C.
        • Grau-Sepulveda M.V.
        • et al.
        Reoperation after transcatheter aortic valve replacement: an analysis of the Society of Thoracic Surgeons Database.
        JACC Cardiovasc Interv. 2020; 13: 1515-1525
        • Rogers T.
        • Greenspun B.C.
        • Weissman G.
        • et al.
        Feasibility of coronary access and aortic valve reintervention in low-risk TAVR patients.
        JACC Cardiovasc Interv. 2020; 13: 726-735
        • Alkhouli M.
        The unrelenting search for bioprosthetic aortic valve durability.
        JACC Cardiovasc Imaging. 2020; 13: 354-356
        • Chamandi C.
        • Barbanti M.
        • Munoz-Garcia A.
        • et al.
        Long-term outcomes in patients with new permanent pacemaker implantation following transcatheter aortic valve replacement.
        JACC Cardiovasc Interv. 2018; 11: 301-310