Abstract 4359607: Short-Term Gains, Long-Term Costs: Transcatheter Versus Surgical Aortic Valve Replacement in Heart Failure with Reduced Ejection Fraction

Background: Despite its growing use as a less invasive alternative to SAVR in severe aortic stenosis, outcomes of TAVR in HFrEF patients remain under-investigated. Methods: Using TriNetX, we retrospectively compared 1-, 6-, 12-, and 24-month outcomes after first-time TAVR versus SAVR in propensity-score-matched adults (≥18 years) with nonrheumatic aortic stenosis and HFrEF (Jan 2012–Dec 2022), excluding those with congenital valve malformations, prior prostheses, aortic insufficiency, stage 4-5 CKD or dialysis, preserved EF, or cross-exposure (i.e., receipt of both TAVR and SAVR). Results: Among 417 propensity-matched patients (mean age 70 y; 74 % male), at 1 month, TAVR was associated with lower risks of all-atrial fibrillation (RR 0.54; p < 0.001), paroxysmal AF (RR 0.68; p = 0.023), acute kidney injury (RR 0.46; p < 0.001), cardiogenic shock (RR 0.27; p < 0.001), major bleeding (RR 0.33; p < 0.001) and hospitalization (RR 0.77; p = 0.041), but a higher risk of pacemaker/ICD implantation (RR 1.72; p = 0.009); SAVR alone had more aortic dissections (10 vs 0; p = 0.001). At 6 months, TAVR showed increased risks of ventricular tachycardia (RR 2.07; p = 0.02), acute coronary syndrome (RR 1.70; p = 0.02), left bundle branch block (RR 1.97; p < 0.001), debility (RR 1.96; p = 0.012) and pacemaker/ICD implantation (RR 1.63; p = 0.007), alongside reduced risks of all-atrial fibrillation (RR 0.64; p < 0.001), paroxysmal AF (RR 0.72; p = 0.03), acute kidney injury (RR 0.58; p = 0.002), cardiogenic shock (RR 0.38; p = 0.002) and bleeding (RR 0.38; p < 0.001). At 12 months, ventricular tachycardia remained higher (RR 2.65; p < 0.001) and bleeding remained lower (RR 0.44; p < 0.001). At 2 years, TAVR was associated with higher rates of major adverse cardiovascular events (RR 1.51; p = 0.001), ventricular tachycardia (RR 1.93; p = 0.003), acute coronary syndrome (RR 1.68; p = 0.003), and all-cause mortality (RR 1.91; p = 0.001), but lower rates of all-atrial fibrillation (RR 0.76; p < 0.001), bleeding (RR 0.63; p = 0.001) and cardiogenic shock (RR 0.42; p = 0.001). Conclusion: In patients with HFrEF, TAVR was associated with favorable early safety outcomes, including lower rates of atrial fibrillation, bleeding, acute kidney injury, and cardiogenic shock. However, by 2 years, higher risks of ventricular arrhythmias, acute coronary syndrome, and mortality raise concerns about its long-term durability compared to SAVR.