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NEW ORLEANS -- Surgery continues to dominate contemporary aortic valve replacement (AVR) for young and middle-aged adults nationwide, according to research.

From the Society of Thoracic Surgeons (STS) National Database, 55% of AVR patients received bioprosthetic surgical valves, 42% mechanical valves, and just 1.0% transcatheter aortic valve replacement (TAVR) among the more than 45,000 patients who were 18-54 years old.

However, TAVR use was up 167% from 2013 to 2018, reported Jennifer Nelson, MD, MS, of Nemours Children's Health System in Orlando, Florida, during a press conference at the .

"Guideline modifications for valve utilization and expanded indications for TAVR have led to a shifting landscape for adult AVR," she said.

The investigators found especially low 3o-day mortality and morbidity rates with isolated AVR procedures, surgical or transcatheter. "TAVR mortality was similar to that of bioprosthetic SAVR [surgical aortic valve replacement]," Nelson noted.

Comparing the 46% of SAVRs that were performed without concomitant procedures to isolated TAVR, the researchers found the following outcomes:

• Mortality at 30 days: 1.6% vs 2.9% (not significant)

• Morbidity: 16% vs 17% (not significant)

• Stroke: 0.9% vs 2.4% (P=0.002)

• Permanent pacemaker implants: 3.7% vs 3.6% (not significant)

• Length of stay: 6 vs 4 days (P<0.001)

"Our research favors the use of SAVR in adults who are younger than 55 years old," Nelson said in a press release. "Although young and middle-aged adult TAVR candidates do exist, thoughtful patient selection is critical to optimizing triage to SAVR and TAVR."

"However, as the durability of these valves and the benefits in other types of valve dysfunction become known through longer-term follow up, I expect the TAVR trend will continue toward younger and younger patients," she added.

It's "indisputable" that TAVR has disrupted technology in aortic stenosis, according to the moderator of the press conference, Robbin Cohen, MD, of the University of Southern California in Los Angeles.

"No one can argue with the excellent short-term results [of a] procedure that's practically incision-less and painless," he said. "Why wouldn't all patients want this and us give this to them?"

However, he continued in the press release: "Despite the excellent results and less invasive nature of TAVR in older adults, we need to exercise caution before offering this technology to younger patients. "We just don't know enough about the durability of TAVR in young patients, nor do we know what the best treatment option will be should TAVR valves fail from structural deterioration and need to be replaced."

Nelson and colleagues found that patients with congenital heart disease (CHD) constituted 16% of the total cohort. They are a unique group, she said, being younger, with fewer measured risk factors, and a higher prevalence of prior aortic valve intervention.

In this congenital subgroup, mechanical valves were placed in 51%, bioprosthetic ones in 44%, and TAVR in 0.5% of patients.

They had particularly low 3o-day mortality after any type of AVR. Morbidity too was lower for them than for other patients after SAVR, but higher after TAVR.

Adults with CHD represent "a large and growing subgroup, but the anatomy of the aorta, aortic valve, and coronary arteries could present challenges for current TAVR devices," Nelson noted in the press release. "However, adults with CHD often have undergone several procedures in their lifetimes, so we must evaluate new therapies that could potentially avoid open, invasive operations."

She said the researchers were unable to probe the reasons for valve selection or to assess functional recovery, paravalvular leak, hemodynamics, or durability.

"A prospective trial is needed to refine optimal patient selection and match patients to their most appropriate valve type," Nelson said.

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