TAVR Rates Exceed SAVR in Practice, Linked to Worse Survival in Older Adults

Natalia N. Egorova, PhD

Credit: Mount Sinai

Consensus guidelines endorse surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) for individuals aged ≥65 with severe aortic stenosis, but a recent statewide analysis highlights a predominant use of TAVR over SAVR.

Presented at the 2024 Society of Thoracic Surgeons (STS) Annual Meeting, the analysis found that TAVR rates still exceeded SAVR rates among older patients in California, and the procedure was associated with significantly worse risk-adjusted 5-year survival.¹

“Despite consensus guideline recommendations for SAVR over TAVR in patients aged <65 years, TAVR use exceeds SAVR in patients aged <60 years in California and is associated with significantly worse 5-year survival,” wrote the investigative team, led by Natalia N. Egorova, PhD, a professor of population health science and policy at the Ichahn School of Medicine at Mount Sinai.

Class 1 recommendations from the 2020 American College of Cardiology (ACC)/American Heart Association (AHA) consensus guidelines advocated for the use of SAVR over TAVR in patients with severe aortic stenosis.² For this analysis, Egorova and colleagues aimed to evaluate both clinical practice and mid-term outcomes of TAVR and SAVR among an older population with severe aortic stenosis.¹

Using the Department of Health Care Access and Information (HCAI) database, the team identified over 37,000 patients undergoing TAVR or SAVR between 2013 and 2021 in California. Of this population, 2360 patients aged <60 years had undergone a procedure, including 523 TAVR (22.2%) and 1,837 SAVR (77.8%) procedures.

Patients undergoing TAVR had a median follow-up of 2.4 years after the procedure, while patients undergoing SAVR had 4.9 years of follow-up post-procedure. For the analysis, the primary outcome was 5-year survival. Secondary outcomes consisted of the cumulative incidence of reoperation, infective endocarditis, stroke, and readmission with heart failure assessed using competing risk analysis at both 30 days and 5 years.

The analysis used propensity score matching for 31 patient characteristics, including age, major comorbidity, hospital volume, and urgency, to create TAVR and SAVR groups. Overall, the analysis generated 358 pairs. Investigators used joinpoint regression analysis to calculate the annual percent change (APC) in procedure rate to assess practice trends.

During the study period, the analysis found the rate of TAVR for those aged <60 years significantly increased from 7% in 2013 to 62% in 2021 (APC, 4.7%; P <.001). Comparing SAVR versus TAVR, the 30-day mortality was similar (0.2% versus 0.4%; P = .2), while the 5-year survival was significantly better for SAVR (98% vs. 86%; P <.001).

Further analysis revealed the 5-year observed cumulative incidence of reoperation (2.2% vs. 3.8%; P = .25), stroke (1.1% vs. 0.8%; P = .39), infective endocarditis (0.8% vs. 0.4%; P = .38), and heart failure readmission (1.9% vs. 1.2%; P = .10) was similar for SAVR and TAVR.

Among the propensity-matched population, the 5-year survival rate significantly improved after SAVR (93% vs. 88%; hazard ratio [HR], 2.5; 95% CI, 1.1 - 3.7; P = .02). Investigators identified a lack of significant difference in the cumulative incidence of secondary outcomes in the matched cohort.

Out of 97 hospitals offering TAVR in California, 67 performed the procedure in patients younger than 60 years (69.1%). Egorova and colleagues found the median surgical volume of hospitals was similar after stratifying by TAVR procedure in patients <60 years (197 versus 198; P = .73).

Based on the significantly worse risk-adjusted 5-year survival in TAVR, the investigative team called for further randomized trials and coverage determinations to support appropriate practice for older patients with severe aortic stenosis.

References

1. _{Alabbadi S, Malas J, Chen Q, Cheng W, Tam D, Bowdish M, Chikwe J, Egorova N. Guidelines versus Practice: A Statewide Sruvival Analysis of SAVR versus TAVR in Patients Aged <60 Years. Presented at the 2024 Society of Thoracic Surgeons Annual Meeting, January 27-29, 2024.}
2. _{Writing Committee Members, Otto CM, Nishimura RA, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg. 2021;162(2):e183-e353. doi:10.1016/j.jtcvs.2021.04.002}