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Aortic Valve Replacement in Young and Middle-Aged Adults: Current and Potential Roles of TAVR

The Annals of Thoracic Surgery
Volume 112, Issue 1, P132-138, July 01, 2021, DOI: https://doi.org/10.1016/j.athoracsur.2020.05.180

Jennifer S. Nelson, MD, MS, Timothy M. Maul, PhD, CCP, Peter D. Wearden, MD, PhD, Hani K. Najm, MD, MSc, Orkun Baloglu, MD, Douglas R. Johnston, MD, Tara Karamlou, MD, MSc

Abstract

Background

Contemporary practice patterns and outcomes for aortic valve replacement (AVR) among young and middle-aged adults are unknown given guideline modifications for surgical AVR (SAVR) and increasing transcatheter AVR (TAVR) acceptance. This study describes SAVR and TAVR use and outcomes using The Society of Thoracic Surgeons (STS) National Databases.

Methods

Adults 18 to 55 years of age in the Congenital Heart Surgery Database (CHSD) and the Adult Cardiac Surgery Database (ACSD) who underwent SAVR or TAVR from 2013 to 2018 were included. Perioperative characteristics and early outcomes were described by valve type. Multivariable regression identified determinants of death, length of hospital stay, and a composite end point of renal failure, persistent neurologic deficit, readmission, and reoperation.

Results

The study analyzed 1580 unique CHSD and 44,173 ACSD operations, 16% of which were performed in patients with congenital heart disease. Valve use included the following: TAVR, 1%; mechanical, 42%; bioprosthetic, 55%; autograft, 0.6%; homograft, 1.2%; and Ozaki, 0.4%. Over time, TAVR volumes increased by 167%. The 30-day mortality was as follows: TAVR, 3.8%; mechanical, 3.2%; bioprosthetic, 3.7%; autograft, 0.6%; homograft, 9%; and Ozaki, 3.4%. Stroke rate was lower for isolated SAVR vs isolated TAVR (0.9% vs 2.4%; P = .002). In multivariable analyses, mortality risk was lower with mechanical valves, congenital morbidity risk was higher with TAVR, and length of stay was shorter with TAVR.

Conclusions

TAVR is increasingly used for adults younger than 55 years of age. Given the uniformly excellent results with SAVR, including both mortality and morbidity—particularly regarding stroke, our data favor SAVR in this population, but a prospective trial is needed. Ongoing efforts to harmonize variables and outcomes definitions between the ACSD and CHSD are valuable.

Full Article

Commentary

Transcatheter aortic valve replacement (TAVR) adds to surgical aortic valve replacement (SAVR) in recent years. Besides an increasing amount of TAVR, a shift of potential recipients to young and middle-aged patients could be noted. Especially in patients with congenital heart defects (CHD), with previous valve operations, the avoidance of multiple sternotomies is in question to be beneficial.

Nelson and colleagues, reported in their article “Aortic Valve Replacement in Young and Middle-Aged Adults: Current and Potential Roles of TAVR”, on the comparison of SAVR and TAVR. Using the STS National Database, 45,753 records of adults between 18 and 55 years of age, were analyzed, including patients with CHD (16%). The volume of TAVR increased by 167% in five years. A description of practice patterns gives an overview of current valve types and their use in linkage to age groups. Outcomes focusing on early mortality, morbidity, length of stay, and readmission are given enhanced with multivariate factor analysis. Overall, 30-day mortality was 3.6%, with a range of 0.7 to 9.6% across valve types. Key findings of the research are very nicely summarized in the first paragraph of the comments section. The included tables give a good overview comparing valve types. 

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