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

Objectives Although surgical aortic valve replacement (SAVR) has a class 1 A recommendation for treating severe aortic stenosis in patients <65 years, transcatheter aortic valve replacement (TAVR) in this population is increasing. This study evaluates the impact of hospital variation in TAVR use in patients <65 years on clinical outcomes. Methods Using US 3-state data from 2013 through 2021, we assessed the hospitals' preference for TAVR vs SAVR by generating the observed-to-expected TAVR ratio. Hospitals were ranked into tertiles based on their ratio. The risk of mortality, stroke, infective endocarditis (IE), and permanent pacemaker implantation (PPI) for patients undergoing aortic valve replacement (AVR) in each tertile was assessed at 30 days and 6 years using logistic regression and Cox-proportional hazard models. Results Among 189 hospitals, 103 were in the low, 55 in the medium, and 31 in the high-tertile. Patients who underwent AVR in the high tertile had lower rates of comorbidities than patients in mid or low tertiles. Patients at high and medium ratio hospitals had higher rates of PPI at 30 days than those from low TAVR-use hospitals (17% vs 7.6% vs 5.6%, P <. 001). Patients in the high vs low tertile experienced a higher 6-year risk-adjusted mortality (8.1% vs 5.3%, HR: 1.63 [1.37-1.93], P <. 001), stroke (2.2% vs 1.1%, sub-distribution hazard ratio [sHR]: 2.15 [1.50-3.06], P <. 001), and IE (2.9% vs 0.3%, sHR: 9.91 [5.59-17.56], P <. 001). Conclusions The decision on TAVR utilization in patients younger than 65 should be made carefully considering the patient's clinical profile and life expectancy.