The Age of Opportunity in Aortic Valve Interventions: Beyond Traditional Boundaries for Transcatheter Aortic Valve Replacement in Younger Patients

The aortic valve replacement (AVR) strategy initially chosen in patients with severe aortic stenosis has a far-reaching impact on the lifetime management of the patient's aortic valve disease.The current American College of Cardiology/American Heart Association guidelines provide a class IA recommendation for surgical aortic valve replacement (SAVR) in patients younger than age 65 years with an indication for AVR and a life expectancy >20 years, and stratify the decision between bioprosthetic and mechanical valves based on the patient's ability to tolerate oral anticoagulation. 1 As approval for transcatheter aortic valve replacement (TAVR) has expanded to include patients at all levels of surgical risk, so has the utilization of TAVR in younger patients.Recent data indicate that TAVR now accounts for nearly half of isolated AVR in patients aged <65 years. 2 These data have called into question why many patients aged 50-64 years are being treated with TAVR, given that this contradicts current practice guidelines.It is in this context that Ismayl et al 3 report contemporary trends and outcomes of over 28,000 patients aged 50 to 64 years treated with isolated AVR in the United States from 2016-2021.Utilizing the National Readmission Database, the authors report that the proportion of patients aged 50-64 years treated with TAVR increased from 12.6% to 41.4% over this time.After propensity score adjustment, the authors found that TAVR was associated with lower rates of in-hospital mortality, stroke, acute kidney injury, major bleeding, and blood transfusion, but higher rates of permanent pacemaker implantation and vascular complications than SAVR.Although TAVR was associated with shorter length-of-stay and lower hospital costs, it was also associated with higher readmission rates at 90 and 180 days.The authors should be commended on this thorough and thought-provoking analysis of trends in TAVR utilization in this younger age group, of which we currently have limited evidence; however, these results should be framed with certain caveats, and caution should be used when drawing conclusions about the inappropriateness of TAVR in this age group during this time frame.