STS Reports Study Findings of SAVR Versus TAVR in Patients Aged < 60 Years

February 5, 2024—The Society of Thoracic Surgeons (STS) recently announced the presentation of a study showing that many hospitals opt for a nonsurgical approach to treat patients aged < 60 years with severe aortic stenosis (AS), possibly with poorer survival rates and despite national guidelines recommending surgical aortic valve replacement (SAVR) for patients aged < 65 years with severe AS.

Investigators compared outcomes for patients undergoing SAVR and those undergoing nonsurgical or transcatheter aortic valve replacement (TAVR) from 2013 to 2021 in California.

The investigators were from the Department of Cardiac Surgery at the Smidt Heart Institute at Cedars-Sinai in Los Angeles, California, and the Department of Population Health Science and Policy at Mount Sinai New York in New York, New York. Joanna Chikwe, MD, Chair of the Department of Cardiac Surgery at the Smidt Heart Institute at Cedars-Sinai, is senior investigator.

The study’s findings were presented at the STS 2024 annual meeting held January 27-29 in San Antonio, Texas.

According to the STS press release, the 2020 consensus guidelines of the American College of Cardiology and American Heart Association (announced in December 2020) recommended surgery over TAVR in patients aged < 65 years with severe AS. The investigators sought a real-world snapshot of how hospitals are treating patients in an even younger cohort.

From a pool of 37,011 patients, the study identified 2,360 patients aged < 60 years who underwent these procedures, with 22% receiving TAVR and 78% SAVR. By 2021, approximately half of patients aged < 60 years were receiving TAVR rather than SAVR. The investigators followed these patients for a median time of 2.4 years after TAVR and 4.9 years after SAVR to assess their outcomes.

As summarized in the STS press release, the primary focus was on 5-year survival rates. Secondary outcomes included rates of reoperation, infective endocarditis, stroke, and hospital admissions for heart failure. Propensity score matching ensured a fair comparison of 358 pairs of patients, balancing factors such as age, major health conditions, hospital volume, and urgency.

Although the 30-day mortality rates were similar for SAVR and TAVR (0.2% vs 0.4%), the 5-year survival rate was significantly better after SAVR compared to TAVR (98% vs 86%; P < .001). For secondary outcomes, there was no significant difference between the two groups.

“While we expected that the volume of transcatheter therapy would increase over the study period in this young patient cohort, we were surprised there appears to be near equipoise in terms of procedure selection, with patients and clinicians opting for procedures against the 2020 guidelines,” commented study investigator Jad Malas, MD, in the STS press release. Dr. Malas is a cardiothoracic surgery resident at Cedars-Sinai Medical Center.

Additionally, Dr. Chikwe stated in the press release, “The study results indicate a need for randomized trials in younger patients (who represent fewer than 10% of the patients in randomized trials comparing these treatments)—as well as more balanced and informed patient-centered decision-making—to support more appropriate practice in this younger patient population.”

She further noted that her research group has expanded their analysis to include a multistate registry for better comparison of the two procedures.

Dr. Chikwe concluded, “As cardiac surgeons, we owe it to our patients to take a more prominent role in providing the highest quality evidence to help our patients make these major health care decisions. While transcatheter therapy appears more attractive to most patients, there are clearly long-term benefits with surgical therapy for the lifetime management of valvular heart disease in many patients.”