Real-world Outcome and Long-Term Survival Analysis after Trans-Catheter Aortic Valve Implantation (TAVI) - Does Age Matter?

Background Transcatheter aortic valve implantation (TAVI) is the treatment of choice in elderly patients irrespective of surgical risk. Since a clear cut-off in age is still a matter of debate during heart team decision making between TAVI and surgical aortic valve replacement (SAVR), outcome data of younger patients undergoing TAVI due to high surgical risk are of great clinical interest. Thus, the current study aimed to compare outcome and long-term survival data in typical elderly versus younger TAVI patients. Methods and Results This single-center outcome and up to 2-year survival analysis reports data of 619 patients (mean age: 79 ± 7 years; 50% female; mean STS score 4.7 ± 3.9%) that underwent transfemoral TAVI between August 2016 and September 2020. The cohort was classified into typical elderly (> 70 years, n=542) and younger (≤ 70 years, n=77) patients. Mortality rates were available for all patients at 30 days, 1 year and 2 years after TAVI. The STS score was 5.0 ± 4.0% in elderly compared to 2.8 ± 2.2% in younger subjects (p < 0.001). The main devices implanted were the balloon-expandable Edwards Sapien 3 (61% in) and the self-expanding Medtronic EvolutR (36%) device without differences between the groups (p=n.s.). The procedural success rate in the total cohort was > 99% and we identified the following prevalence rates of peri- and postprocedural complications (each in comparison between elderly vs. younger patients): acute vascular complications - 6.1% vs. 5.4% (p=n.s.); bleedings requirement of transfusion - 9.2% vs. 2.7% (p=0.059); disabling strokes - 2.3% vs. 1.4% (p=n.s.); requirement of new pacemakers - 11.1% vs. 3.9% (p=0,052) and acute kidney injuries - 2.7% vs. 1.4% (p=n.s.). At the 6 weeks follow-up, both, elderly and younger patients reported improvement of symptoms (NYHA class), which was underlined by a significant decrease in brain natriuretic peptide (BNP) and improved 6-minutes’ walk distances (SMWD) (p<0.001 for each parameter). While there were no differences between the groups for NYHA class and BNP (p=n.s.), SMWD was higher in younger patients (p<0.001). Interestingly, Kaplan Meier analysis revealed the following short- and long-term mortality rates (each in comparison between elderly vs. younger patients): 3.4% vs. 1.3% after 30 days (p=n.s.); 17.2% vs. 10.5% after 1 year (p=n.s.) and 25.2% vs. 17.1% after 2 years (p=n.s.; figure 1). Conclusion The results of this real-world analysis demonstrate that TAVI in younger patients not eligible for surgery after heart team evaluation is safe and not inferior compared to a typical elderly cohort, especially regarding complication rates, clinical outcomes and mortality until 2 years after implantation. Thus, younger age alone should not discard TAVI as therapeutic option for AS in cases with either high surgical risk or other individual factors speaking against surgery at the time when treatment is indicated.