Hospital-Level Variation in Transcatheter vs Surgical Aortic Valve Replacement Among Patients Younger Than 65 Years

Current guidelines do not recommend transcatheter aortic valve replacement (TAVR) in adults aged <65 years with isolated aortic stenosis and a life expectancy >10 years.

This retrospective cohort study was conducted using the Vizient Clinical Database in adults aged <65 years with isolated aortic stenosis who underwent aortic valve replacement (AVR) with a bioprosthetic valve between 2018 and 2023. Hospital-level variation in TAVR vs surgical AVR (SAVR) was evaluated using multilevel multivariable logistic regression.

Among 13,907 AVRs, 6142 (44.2%) were SAVR, and 7,765 (55.8%) were TAVR. The median hospital TAVR rate was 52.9% (interquartile range, 35.3%-70.7%). Among patients at the lowest surgical risk (predicted mortality <0.5%), 46.5% underwent TAVR. Patients treated at hospitals with higher risk-adjusted TAVR vs SAVR use had a 2.7-fold higher odds of undergoing TAVR than patients treated at hospitals with a lower risk-adjusted rate (median odds ratio, 2.69; 95% CI 2.43-3.02). Lower-volume hospitals (based on total AVR volume [SAVR plus TAVR]) performed fewer TAVRs vs SAVRs compared with higher-volume hospitals. Teaching status, Disproportionate Share Hospital Percentage, rurality, and average daily census were not significantly associated with TAVR use.

Substantial variation exists in hospital rates of TAVR vs SAVR among patients aged <65 with isolated aortic stenosis, even after adjusting for patient characteristics. Nearly half of the lowest-risk patients (mortality <0.5%) aged <65 underwent TAVR instead of SAVR. These findings suggest that practice patterns and nonclinical factors may influence procedure selection in this population.