Surgical versus 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 United States Centers for Medicare Services database, all patients aged 65-85 undergoing isolated first-time SAVR (n=34,215) or TAVR (n=124,897) were evaluated (2018-2022). Predicted patient risk accounting for comorbidities simulating 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=9,693 SAVR), or High (>8%, n=44,574 TAVR, n=9,841 SAVR). 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 to TAVR across all risk strata (all p<0.05). Longitudinal 5-year analysis highlighted that, compared to TAVR, SAVR was associated with superior freedom from composite death, stroke, or valve reintervention in low and intermediate risk patients (HR 0.85, p=0.044, and HR 0.86, p=0.039, respectively) as well as lower overall readmission for stroke in low (HR 0.72, p=0.038) and intermediate (HR 0.78, p=0.042) 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.