Temporal trends of aortic valve replacement modalities by age group in the United-States 2015 - 2023
Why the study?
The impact of ACC/AHA guideline age group classification on contemporary aortic valve replacement practice in the U.S. remains of interest and is dynamically changing.
What are the temporal trends in the utilization of TAVI versus SAVR across different age groups in the US between 2015 and 2023?
Key Points
- To evaluate nationwide temporal trends in the utilization of transcatheter aortic valve implantation versus surgical aortic valve replacement across different age categories in the United States.
- Retrospective analysis of de-identified data from the Vizient Clinical Database encompassing over 1,000 medical centers between October 1, 2015, and November 30, 2023.
- Included 467,832 adult patients with aortic stenosis undergoing aortic valve replacement, categorized into three age brackets: <65, 65–80, and >80 years.
- Temporal trends for transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) were analyzed using linear regression.
- Overall adoption of TAVI increased significantly nationwide from 33.5% in 2015 to 59.96% in 2023 out of 467,832 total procedures (TAVI n=252,834; SAVR n=214,998).
- In patients >80 years, TAVI rose from 69.95% to 92.96% (p<0.002); in those aged 65–80 years, it rose from 26.23% in 2015 to ~60% in 2020 (p=0.001) before reaching a plateau.
- In patients <65 years, TAVI increased from 7.18% in 2015 to 19.12% in 2020 (p<0.002), followed by a slight decline to 16.36% in 2023.
Study Design
Type
Observational (n=467,832)
Multicenter
Yes
Structured PICO
What are the temporal trends in the utilization of TAVI versus SAVR across different age groups in the US between 2015 and 2023?
P
Population
467,832 adult patients with aortic stenosis who underwent aortic valve replacement between 2015 and 2023 across more than 1,000 U.S. medical centers.
E
Exposure
Transcatheter aortic valve implantation (TAVI)
C
Comparator
Surgical aortic valve replacement (SAVR)
O
Outcome
Temporal trends in the modality of AVR (TAVI vs SAVR) among different age groups
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
SSSachin S. GoelInterventional cardiologist, Houston Methodist DeBakey Heart Center
“We should ask, however, if this indication creep for TAVR in younger, low-risk patients is based on the data or just the desire (of both patients and physicians) for TAVR.”
TKTsuyoshi KanekoCardiothoracic surgeon, Washington University School of Medicine
“Despite that, 29% of TAVR usage where the guidelines clearly recommend class one indication for SAVR in non-high-risk patients is very high. The age creep and the risk creep in this group is very concerning.”
“The use of TAVR has expanded very fast. Now intermediate risk groups, often comprised of people younger than 65, are becoming eligible for the procedure. This is concerning because there is limited knowledge on the longevity of the bioprosthetic valves.”
Implication
TAVI utilization has plateaued in older age groups and recently decreased slightly in patients <65 years, indicating real-world alignment with the 2020 ACC/AHA guidelines.
Abstract
Background/Introduction Transcatheter aortic valve implantation (TAVI) has led to a paradigm shift in treating aortic stenosis (AS) across patients of all surgical-risk categories. To guide the clinical decision, the ACC/AHA guidelines recommended an age group classification; with SAVR being recommended in patients < 65 years, and TAVI being favored over SAVR in patients > 80 years. In patients between 65-80 years, both modalities are to be considered after shared decision making. The impact of those guidelines-derived age group classification on the contemporary AVR practice remains of interest and is dynamically changing. Purpose This study aims to examine the temporal trends in the modality of AVR (TAVI vs SAVR) in the U.S. among different age groups using a contemporary nationwide database. Methods We conducted a retrospective study using de-identified data from the Vizient Clinical Database, which gathers patient and hospital data from more than 1000 medical Centre. We analysed TAVI and SAVR procedures from October 1, 2015, to November 30, 2023, excluding patients under 18. We examined the national trends of TAVI vs SAVR in 3 age groups (<65, 65-80, >80 years) with AS. Trend analysis was performed using linear regression. This study was deemed exempt from the requirements of 45 CFR 46.104(d) by The Miriam Hospital Institutional Review Board given that it involved de-identified data. Results During the study period, 467,832 underwent AVR (TAVI n= 252,834, SAVR n= 214,998). The patient and hospital characteristics by age group are summarized in the Table. We observed a significant rise in TAVI adoption from 33.5% in 2015 to 59.96% in 2023. However, the pattern of temporal trends varied among different age groups. In patients > 80 years, TAVI showed a steep rise from 69.95% in 2015 to 92.96% in 2023 (p<0.002). The 65-80 years age cohort demonstrated the most pronounced growth in TAVI, rising from 26.23% in 2015 to about 60% in 2020 (p.001), after which a plateau in percentage was observed. TAVI in patients <65 years has also been increasingly adopted, rising from 7.18% in 2015 to 19.12% in 2020 (p<0.002), however, followed with a slight downtrend to 16.36% in 2023 (Figure). Conclusion In this most contemporary analysis from the U.S., we demonstrate an increase in the adoption of TAVI across all age groups over the study period, with the steepest rise observed in patients between 65-80 years of age. Since the 2020 ACC/AHA guidelines, there has been a gradual downtrend in the utilisation of TAVI in patients <65 years of age indicating a possible change in practice based on scientific societal recommendations. The stabilization in TAVI percentage in the age groups 65-80 years and > 80 years in the last few years may hint towards approaching equilibrium between TAVI and SAVR for these age groups.
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Cite This Study
Barghout et al. (2024) conducted an observational in Aortic stenosis (n=467,832). Transcatheter aortic valve implantation (TAVI) vs. Surgical aortic valve replacement (SAVR) was evaluated on Temporal trends in the modality of aortic valve replacement (TAVI vs SAVR).