Hospital Variation in Aortic Valve Replacement Approach Selection for Aortic Stenosis in Patients Under 65

Area of Science:

• Cardiovascular Surgery
• Interventional Cardiology
• Health Services Research

Background:

• Surgical aortic valve replacement (SAVR) is recommended for severe aortic stenosis in patients <65 years.
• Transcatheter aortic valve replacement (TAVR) use is increasing in this younger population.
• Hospital variation in TAVR adoption exists, necessitating outcome evaluation.

Purpose of the Study:

• To evaluate the impact of hospital variation in TAVR use among patients <65 years on clinical outcomes.
• To assess how hospital TAVR preference influences mortality, stroke, infective endocarditis, and permanent pacemaker implantation.

Main Methods:

• Utilized US 3-state data (2013-2021) to calculate observed-to-expected TAVR ratios per hospital.
• Hospitals were categorized into tertiles (low, medium, high TAVR use) based on their ratios.
• Logistic regression and Cox-proportional hazard models assessed 30-day and 6-year risks for mortality, stroke, IE, and PPI.

Main Results:

• Hospitals with high TAVR ratios had patients with fewer comorbidities.
• Higher rates of permanent pacemaker implantation (PPI) were observed at 30 days in high and medium TAVR-use hospitals (17% vs 7.6% vs 5.6%).
• Patients at high TAVR-use hospitals faced increased 6-year risks for mortality (8.1% vs 5.3%), stroke (2.2% vs 1.1%), and infective endocarditis (IE) (2.9% vs 0.3%).

Conclusions:

• Hospital variation in TAVR utilization for patients <65 years is associated with differing clinical outcomes.
• Higher TAVR adoption rates correlate with increased risks of mortality, stroke, and IE.
• Patient selection for TAVR in younger individuals (<65 years) requires careful consideration of clinical profile and life expectancy.