Surgeries & Interventions

SAVR’s Value in the TAVR Era

Procedure trends certainly suggest that we’ve entered the TAVR era, but a pair of new studies show that surgical aortic valve replacement (SAVR) is a far better option for many younger and healthier patients who are increasingly seen as TAVR candidates.

In the first study presented at The Society of Thoracic Surgeons’ 2024 Annual Meeting, researchers analyzed outcomes from 37k California-based patients who underwent SAVR or TAVR between 2013 to 2021…

  • Of the 2,360 patients under the age of 60, 22% received TAVR and 78% received SAVR.
  • However, the ratio of under-60 patients who underwent TAVR increased from 7% in 2013 to 62% in 2021.

TAVR’s under-60 surge appeared to lead to worse overall outcomes, as SAVR patients had significantly better 5-year survival rates (98% vs. 86%) even when comparing a propensity-matched population (93% vs. 88%).

Given these 5-year survival rates, the researchers called for more RCTs and coverage determinations to support aortic valve replacement decision making, especially as TAVR continues to trend towards younger and healthier patients.

A second study in The Annals of Thoracic Surgery further detailed SAVR’s rapid volume declines, while highlighting certain patients who remain better off with surgery. The researchers analyzed 200k nationwide adults who underwent SAVR between 2011 and 2022, finding that…

  • Annual SAVR volumes decreased by 45% (19,560 to 10,851).
  • The proportion of SAVR patients increased in the <65yr patient group (26.2% to 54.5%), but declined among 65-79yr (49.2% to 43.6%) and ≥80yr patients (24.7% to 1.9%).

Much of these SAVR declines occurred in patients with tricuspid aortic valves (from 84.5% to 55% of total SAVRs), while SAVR ratios increased among patients with bicuspid aortic valves (from 15.5% to 45%). 

That’s a positive trend given that <80yr SAVR patients with bicuspid aortic valves also had better-than-expected mortality rates. It was also strong enough evidence for the authors to encourage changing the STS-ACSD risk model based on aortic valve morphology, and to suggest that SAVR should remain the preferred therapy among <80yr patients with bicuspid aortic valves.

The Takeaway

The “transcatheter era” has brought a surge in TAVR procedures that’s largely outpaced medical evidence and consensus guidelines (which recommend SAVR <65yrs). These new studies suggest that many TAVR patients would have enjoyed better outcomes with SAVR, and reveal a need for revamped trials to clarify which patients would be better off with SAVR or TAVR.

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