Treating younger patients with TAVR increases risk of death
Younger transcatheter aortic valve replacement (TAVR) patients face a heightened risk of death or hospital readmission, according to new data published in JAMA Cardiology.[1] These greater risks may be explained, at least in part, by the higher rates of comorbidities seen in these patients.
“The American College of Cardiology (ACC)/American Heart Association guidelines recommended surgical aortic valve replacement (SAVR) over TAVR for patients younger than 65 years due to a probable life expectancy greater than 20 years, while acknowledging a role for shared decision-making wherein informed patient preferences could be considered,” wrote first author Megan Coylewright, MD, MPH, an interventional cardiologist and editor of the ACC’s CardioSmart program, and colleagues. “Despite these guideline recommendations, three recent analyses indicate a growing percentage of patients younger than 65 years receiving TAVR over SAVR in the past few years.”
Coylewright et al. tracked data from the STS/ACC TVT Registry to learn more, focusing on nearly 140,000 TAVR patients 80 years old and younger. All patients were treated from August 2019 to September 2023. Each patient received a balloon-expandable heart valve from Edwards Lifesciences, and a vast majority of TAVR procedures were performed using transfemoral access. Approximately 6% of patients were younger than 65 years old. The mean age for that group was 59.7 years old and 65.5% were men. The mean age for the remaining patients was 74.1 years old, and 61.8% were men.
Researchers noted that younger patients were more likely to present with a bicuspid aortic valve, congestive heart failure, chronic lung disease, diabetes, a weakened immune system or end-stage kidney disease that requires dialysis. They also had a worse baseline quality of life (QOL); the mean Kansas City Cardiomyopathy Questionnaire (KCCQ) scores were 47.7 for younger patients compared to 52.9 for older patients.
Implant success and complication rates were both similar for these two groups. While in-hospital mortality was slightly more common in younger patients (1%) than older patients (0.7%), the stroke rates were nearly identical. Permanent pacemaker implantation (PPMI), meanwhile, were less common among younger patients (4.3%) than older patients (5.6%).
All-cause mortality was higher for younger patients after 30 days (1.6% vs. 1.4%) and one year (9.9% vs. 8.2%). Stroke rates, on the other hand, were lower for younger patients after 30 days (1.2% vs. 1.5%) and one year (2.2% vs. 2.7%). PPMI rates remained relatively low, but they were lower among younger patients after 30 days (5.8% vs. 7.9%) and one year (7% vs. 9.2%).
In addition, hospital readmissions rates were higher for younger patients after 30 days (7.8% vs. 7.2%) and one year (28.2% vs. 26.1%).
Finally, though QOL data were incomplete, KCCQ scores did improve substantially for both groups. The mean increase after one year was 34 for younger patients and 29.9 for older patients.
“Following successful TAVR, morbidity at one year was significant in this select group of patients younger than 65 years, with more than 28.2% of patients rehospitalized,” the authors wrote. “This refutes the claim that heart teams are rejecting current U.S. guidelines for younger patients with aortic stenosis. Instead, the evidence supports that heart teams continue to use TAVR in patients with a high comorbidity burden. These selected patients are unlikely to have expanded longevity, as they experience significantly higher mortality seen as early as one year postprocedure (9.9%).”
Heart teams demonstrating ‘careful case selection’
The group also emphasized that younger patients still represent a minority of those who are being selected for TAVR. This suggests that even as TAVR gains popularity, cardiologists and their colleagues are not needlessly exposing their youngest patients to transcatheter treatments.
“Current regulatory policies require the participation of a heart team to determine suitability for the procedure,” the authors wrote. “The prevalence of comorbidities affecting longevity among younger patients in this analysis likely reflects careful case selection by local heart teams.”
The team then offered a counter to the common concern that many patients are asking for TAVR—and being treated with it—when they may be a better candidate for SAVR due to their age.
“Data exist from patient preference research that a goal of a minimally invasive procedure falls behind many other decisional attributes for patients,” Coylewright and colleagues wrote. “Thus, the focus for the heart team should remain on listening to informed preferences as a part of the decision-making process.”
Click here for the full analysis.
Michael has more than 18 years of experience as a professional writer and editor. He has written at length about cardiology, radiology, artificial intelligence and other key healthcare topics.