Transcatheter vs Surgical Aortic Valve Replacement for Isolated Native Aortic Regurgitation

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is well established for aortic stenosis, while its application for isolated native aortic regurgitation (AR) was previously off label and technically challenging. Comparative data between TAVR and surgical aortic valve replacement (SAVR) are limited. OBJECTIVES: The aim of this study was to compare patient characteristics and outcomes of off-label TAVR vs SAVR among patients with isolated native AR. METHODS: Using the Centers for Medicare and Medicaid Services Medicare Provider Analysis and Review database, patients ≥65 years of age who underwent TAVR or SAVR for isolated native AR (2017-2023) were identified. Propensity score matching (1:1) was performed to evaluate short- and long-term outcomes. Fine-Gray models accounted for death as a competing risk, reported as subdistribution HRs (SHRs). RESULTS: Among 9,859 patients, 1,742 propensity score-matched pairs were included, with balanced baseline characteristics (mean age 75.8 years vs 75.7 years; female sex 517 of 1,742 [29.7%] vs 528 of 1,742 [30.3%]). In the matched cohort, TAVR was associated with shorter hospitalization (OR: 0.33; 95% CI: 0.28-0.39; P < 0.001) and lower in-hospital mortality (OR: 0.62; 95% CI: 0.39-1.00; P = 0.048) but higher 30-day pacemaker implantation (OR: 1.73; 95% CI: 1.33-2.25; P < 0.001). Through 5 years (median follow-up 2.58 years), TAVR was associated with increased repeat aortic valve replacement (SHR: 2.04; 95% CI: 1.13-3.66) but similar all-cause mortality (HR: 1.14; 95% CI: 0.98-1.31) and heart failure-related readmission (SHR: 1.09; 95% CI: 0.98-1.21) between treatment strategies. CONCLUSIONS: In this analysis, TAVR was associated with shorter hospitalization and comparable 5-year survival as SAVR, although pacemaker and long-term reinterventions rates were higher.