Transcatheter Aortic Valve Replacement in Patients Aged 65 Years and Younger: Unresolved Issues and Future Directions

Introduction: Transcatheter aortic valve replacement (TAVR) has become the predominant treatment for severe aortic stenosis across all surgical risk categories. However, its role in patients aged 65 years and younger remains uncertain, and current guideline recommendations continue to favor surgical aortic valve replacement (SAVR) in this population. Despite this, contemporary real-world data demonstrate a marked increase in TAVR utilization among younger patients, creating an important gap between guidelines and clinical practice. Methods: This review synthesizes contemporary observational evidence evaluating TAVR in patients ≤65 years, with a focus on patient selection, clinical outcomes, and lifetime management considerations. Results: Available studies demonstrate that younger patients undergoing TAVR often represent a highly selected and clinically complex population with greater comorbidity burden, higher surgical risk, and shorter life expectancy than age-matched SAVR recipients, yet substantial hospital-level variation in TAVR utilization exists even after risk adjustment. Mid-term observational data suggest higher mortality and heart failure readmission rates following TAVR compared with SAVR, although these findings are likely influenced by substantial baseline differences between treatment groups. No randomized controlled trial has specifically compared TAVR and SAVR in patients ≤65 years. Furthermore, long-term issues including valve durability, coronary access, redo-TAVR feasibility, and THV optimization remain incompletely understood. Conclusions: TAVR recipients ≤65 are often a clinically distinct group characterized by significantly heavier comorbidity burdens than SAVR recipients of the same age with standard surgical risk models possibly underestimating the true clinical risk. Despite this, significant hospital-level variation in TAVR utilization persists even after risk adjustment, suggesting that institutional practice patterns and other non-clinical factors continue to influence treatment selection.