Surgical vs Transcatheter Aortic Valve Replacement in Patients 65 Years of Age and Older

Abstract

Background: Approval of transcatheter aortic valve replacement (TAVR) for all risk profiles has extended TAVR use in patients not otherwise examined in clinical trials. We sought to evaluate contemporary real-world outcomes of surgical aortic valve replacement (SAVR) vs TAVR in Medicare beneficiaries by risk strata.

Methods: Using the US Centers for Medicare Services database, all patients aged 65-85 years undergoing isolated first-time SAVR (n = 34,215) or TAVR (n = 124,897) were evaluated (2018-2022). Predicted patient risk accounting for comorbidities simulating The Society of Thoracic Surgeons predicted risk of surgical mortality, but including frailty, were stratified by low (<4%, n = 36,297 TAVR; n = 14,693 SAVR), intermediate (4%-8%, n = 44,026 TAVR; n = 9693 SAVR), or high (>8%, n = 44,574 TAVR; n = 9841 SAVR) risk. Doubly robust risk adjustment with inverse probability weighting and multilevel regression with competing-risk time-to-event analyses compared outcomes.

Results: SAVR was associated with higher risk-adjusted in-hospital mortality, acute kidney injury, and bleeding but lower pacemaker rate compared with TAVR across all risk strata (all P < .05). Longitudinal 5-year analysis highlighted that, compared with TAVR, SAVR was associated with superior freedom from composite death, stroke, or valve reintervention in low- and intermediate-risk patients (hazard ratio [HR] 0.85, P = .044, and HR 0.86, P = .039, respectively) as well as lower overall readmission for stroke in low- (HR 0.72, P = .038) and intermediate- (HR 0.78, P = .042) risk patients.

Conclusions: In low- and intermediate-risk Medicare beneficiaries, SAVR was associated with higher in-hospital mortality but superior 5-year longitudinal freedom from death, stroke, or valve reintervention compared to TAVR. These data may further enhance heart team decision-making and patient counseling.