Interventions for valvular disease and heart failure

Clinical outcomes of transcatheter aortic valve implantation in patients younger than 70 years rejected for surgery: the AMTRAC registry

EuroIntervention 2022;17:1289-1297. DOI: 10.4244/EIJ-D-21-00613

Guy Witberg
Guy Witberg1,2, MD; Uri Landes1,2, MD; Pablo Codner1,2, MD; Marco Barbanti3, MD; Roberto Valvo3, MD; Ole De Backer4, MD, PhD; Joris F. Ooms5, MD; Angela McInerney6, MD; Giulia Masiero7, MD; Paul Werner8, MD; Xavier Armario9, MD; Claudia Fiorina10, MD; Dabit Arzamendi11, MD, PhD; Sandra Santos-Martinez12, MD; Jose A. Baz13, MD; Klemen Steblovnik14, MD, PhD; Victor Mauri15, MD; Matti Adam16, MD; Ilan Merdler16, MD; Manuel Hein17, MD; Philipp Ruile17, MD; Marco Russo18, MD; Francesco Musumeci18, MD; Alexander Sedaghat19, MD; Atsushi Sugiura19, MD; Carmelo Grasso3, MD; Luca Branca10, MD; Rodrigo Estévez-Loureiro13, MD; Ignacio J. Amat-Santos12, MD, PhD; Darren Mylotte9, MD, PhD, MBBCh; Martin Andreas8, MD; Matjaž Bunc14, MD; Giuseppe Tarantini7, MD, PhD; Luis Nombela-Franco6, MD, PhD; Lars Søndergaard4, MD; Nicolas M. Van Mieghem5, MD, PhD; Ariel Finkelstein2,16, MD; Ran Kornowski1,2, MD
1. Division of Cardiology, Rabin Medical Centre, Petah-Tikva, Israel; 2. The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; 3. Division of Cardiology, University of Catania, Catania, Italy; 4. The Heart Center, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; 5. Department of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands; 6. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain; 7. Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy; 8. Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; 9. Department of Cardiology, University Hospital Galway, National University of Ireland, Galway, Ireland; 10. Cardiovascular Department, Spedali Civili, Brescia, Italy; 11. Hospital de Sant Creu i Sant Pau Barcelona, Barcelona, Spain; 12. CIBERCV, Hospital Clínico Universitario de Valladolid, Valladolid, Spain; 13. Servicio de Cardiología, Hospital Álvaro Cunqueiro, Vigo, Pontevedra, Spain; 14. Department of Cardiology, University Medical Centre, Ljubljana, Slovenia; 15. Department of Cardiology, Heart Centre, Faculty of Medicine, University of Cologne, Cologne, Germany; 16. Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 17. Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany; 18. San Camillo Forlanini Hospital, Rome, Italy; 19. Herzzentrum Bonn Universitätsklinikum Bonn, Bonn, Germany

Background: The mean age of transcatheter aortic valve implantation (TAVI) patients is steadily decreasing.

Aims: The aim of the study was to describe the characteristics, the indications for and the outcomes of TAVI in patients <70 years old.

Methods: All patients undergoing TAVI (n=8,626) from the 18 participating centres between January 2007 and June 2020 were stratified by age (</>70). For patients <70, the indications for TAVI were extracted from Heart Team discussions and the baseline characteristics and mortality were compared between the two groups.

Results: Overall, 640 (7.4%) patients were <70 (9.1% during 2018-2020, p<0.001); the mean age was 65.0±2.3 years. The younger patients were more often male, with bicuspid valves or needing valve-in-valve procedures. They had a higher prevalence of lung disease and diabetes. In 80.7% of cases, the Heart Team estimated an increased surgical risk and TAVI was selected, reflected by an STS score >4% in 20.4%. Five-year mortality was similar (29.4 vs 29.8%, HR 0.95, p=0.432) in the <70 and >70 groups. In the <70 group, mortality was higher for those referred for TAVI due to an increased surgical risk compared to those referred for other reasons (31.6 vs 24.5%, HR 1.23, p=0.021). Mortality was similar regardless of the STS stratum in patients judged by the Heart Team to be at increased surgical risk (32.6 vs 30.4%, HR 0.98, p=0.715).

Conclusions: Use of TAVI in patients <70 is becoming more frequent. The main reason for choosing TAVI is due to an increased surgical risk not adequately represented by the STS score. The outcomes for these patients are similar to those for older TAVI patients. Dedicated trials of TAVI/SAVR in younger patients are needed to guide decisions concerning expansion of TAVI indications. (( NCT04031274).

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