Retrospective Comparison of Surgical and Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction: A Propensity-matched Analysis of Two Clinically Selected Populations

OBJECTIVE: To determine the impact of surgical aortic valve replacement (SAVR) versus transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS) and reduced ejection fraction (EF). DESIGN: A propensity-matched, retrospective study of consecutive aortic valve interventions from 2010 to 2023. SETTING: A single institution. PARTICIPANTS: Patients with severe AS and reduced EF (<50%) undergoing aortic valve intervention. INTERVENTIONS: The cohort was dichotomized by SAVR versus TAVR. MEASUREMENTS AND MAIN RESULTS: A total of 1,164 patients underwent an aortic valve intervention for severe AS with reduced EF (<50%), of which 240 (20.6%) had an isolated SAVR and 924 (79.4%) underwent a TAVR. Propensity matching yielded 205 pairs. The 30-day mortality and stroke rates were no different across groups. Paravalvular leak was significantly higher in the TAVR group, and there was a statistically nonsignificant trend toward more pacemakers in the TAVR group (p = 0.093). At 1 year, EF was similar between groups: 48% (IQR: 41-53) in the SAVR group versus 53% (IQR: 37-58) in the TAVR group (p = 0.431). Conversely, at 1 year, mean pressure gradients were higher in the TAVR group (10 [7-15] mmHg v 8 [7-10] mmHg, p = 0.040). The cumulative incidence of heart failure readmissions was higher in the TAVR group, although it was a statistically nonsignificant trend (p = 0.066). The cumulative incidence of aortic valve reintervention was similar across groups (p = 0.564). Kaplan-Meier survival estimates were significantly lower in the TAVR group (p = 0.016). CONCLUSIONS: While surgery may optimize survival after aortic valve replacement in patients with reduced EF, these observational findings need to be verified by prospective randomized controlled comparisons.