January 27, 2020
Study From STS Database Supports Surgery Versus TAVR in Young Adults
January 27, 2020—The Society of Thoracic Surgeons (STS) announced study findings showing that open heart surgery remains the best option for young and middle-aged adults with aortic valve disease. According to the study, surgery results in excellent patient survival and fewer strokes compared with transcatheter aortic valve replacement (TAVR), which continues to expand its pool of eligible patients. The study data were revealed during a scientific presentation at the STS 56th annual meeting held January 25–28 in New Orleans, Louisiana.
Jennifer S. Nelson, MD, from Nemours Children’s Hospital in Orlando, Florida, commented in the STS announcement, “Our research favors the use of surgical aortic valve replacement (SAVR) in adults who are younger than 55 years old. Although young and middle-aged adult TAVR candidates do exist, thoughtful patient selection is critical to optimizing triage to SAVR and TAVR.”
As explained in the STS announcement, Dr. Nelson and colleagues from Nemours and the Cleveland Clinic in Cleveland, Ohio, used the STS National Database to examine data from patients aged 18 to 54 years who received aortic valve replacement (SAVR or TAVR) between 2013 and 2018. Approximately one-sixth of these patients had congenital heart disease (CHD). As a result, the investigators combined data from two components of the database: the STS Adult Cardiac Surgery Database (ACSD) and the STS Congenital Heart Surgery Database (CHSD).
Overall, 1,580 unique CHSD and 44,173 ACSD operations were analyzed. More than 15% of the operations were related to CHD. No other complex operations were performed at the same time as aortic valve replacement. When isolated SAVR was compared to isolated TAVR, the stroke rate was 0.9% versus 2.4%, respectively. The investigators also found that the 30-day mortality rate was slightly better for isolated SAVR than isolated TAVR—1.9% versus 2.9%.
TAVR showed an advantage over SAVR in length of hospital stay. SAVR was longer at 6 days versus 4 days for TAVR (with the length of stay for TAVR expected to continue decreasing).
As noted in the press release, Dr. Nelson advised that the number of young and middle-aged adult TAVR candidates is increasing, with TAVR becoming more appealing to younger patients who want to minimize downtime and risks. She said, “The wisdom of extending TAVR to a younger adult population that mirrors the characteristics of an older population with acquired aortic valve stenosis may be reasonable.”
Dr. Nelson explained that among the challenges associated with TAVR in younger patients is that little is known about long-term valve durability.
The investigators also found that patients in this study most often had aortic insufficiency rather than aortic stenosis, the condition for which TAVR valves currently are approved. Therefore, many younger patients may have a type of valve disease that is “not amenable” to treatment currently available for TAVR, explained Dr. Nelson. “However,” she said, “as the durability of these valves and the benefits in other types of valve dysfunction become known through longer-term follow-up, I expect the TAVR trend will continue toward younger and younger patients.”
According to Dr. Nelson, TAVR has been used rarely in young adults and even less in adults with CHD. She said, “Adults with CHD is a large and growing subgroup, but the anatomy of the aorta, aortic valve, and coronary arteries could present challenges for current TAVR devices. However, adults with CHD often have undergone several procedures in their lifetimes, so we must evaluate new therapies that could potentially avoid open, invasive operations. Further study is needed.”
Dr. Nelson recognized TAVR as a “disruptive technology” that has changed the way adult cardiac surgery is practiced. “When handled thoughtfully and responsibly, technological advances such as TAVR can help patients lead longer and fuller lives. As a congenital cardiac surgeon, I seek to define which patients will benefit the most from this new therapy and which patients are better served with other modalities.”
According to Dr. Nelson, the heart team approach that includes an emphasis on shared decision-making and new collaborations between congenital and adult cardiac surgeons has become especially important as the number of aortic valve replacement options increases. She added that when cardiologists and cardiac surgeons together evaluate aortic valve disease cases, patients receive comprehensive counseling and invaluable insight into all the viable options for their valve choice, allowing them to make more informed decisions.
“Because each patient is an individual with unique characteristics, deciding on the best valve option means considering the whole picture. Taking the time to learn about the risks and benefits of each valve option and sharing in the decision-making process with the heart team is the best way to make the right choice,” concluded Dr. Nelson.
In the STS announcement, Robbin Cohen, MD, who was not directly involved with this study, commented, “Despite the excellent results and less invasive nature of TAVR in older adults, we need to exercise caution before offering this technology to younger patients. We just don’t know enough about the durability of TAVR in young patients, nor do we know what the best treatment option will be should TAVR valves fail from structural deterioration and need to be replaced.” Dr. Cohen is Professor of Surgery at the Keck School of Medicine of the University of Southern California in Los Angeles, California.