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.