Determinants of intervention type and mortality of aortic valve replacement in patients younger than 75 years in The Netherlands—a Netherlands Heart Registration study

Backgrounds and aims Despite a restrictive policy concerning transcatheter aortic valve implantation (TAVI) in younger patients, one-fifth of Dutch patients who undergo TAVI are <75 years. We aimed to identify determinants for intervention strategy allocation and all-cause mortality of patients <75 years undergoing aortic valve treatment in the Netherlands. Methods We performed a nationwide analysis using the Netherlands Heart Registration data of TAVI and surgical aortic valve replacement (SAVR) patients between 2015 and 2020. Logistic and Cox regression analyses were used to identify determinants for treatment allocation and all-cause mortality. Effect measures were plotted against prevalence to evaluate the impact of determinants at the population level. Results We included 2200 TAVI patients and 8460 patients with SAVR <75 years. TAVI patients were at a higher risk (65.7% vs. 18.8%). Within risk categories, TAVI patients were older and had more comorbidities than patients with SAVR. Reduced left ventricular ejection fraction (LVEF), lung disease, peripheral artery disease, and previous cardiac surgery characterized TAVI treatment allocation. Five-year mortality for TAVI patients was 43.3%, and for patients with SAVR 12.7%. This difference primarily reflects a fundamental difference in risk phenotype among the TAVI and SAVR cohorts. Lung disease, reduced LVEF, and a non-elective setting were associated with mortality for both therapies. Renal failure, immunomodulatory drugs, and active malignancy were associated with mortality in TAVI patients, but were rare in patients with SAVR. Need for concomitant cardiac surgery was associated with increased mortality in the SAVR cohort. Conclusions In the Netherlands, TAVI patients <75 years had a higher risk phenotype than patients with SAVR, resulting in a higher 5-year mortality. We identified generic and therapy-specific mortality predictors.