Determinants and outcomes of transcatheter aortic valve implantation and surgical aortic valve replacement in patients under 75 with prior cardiac surgery: insights from the Netherlands Heart Registration

BACKGROUND: A history of prior cardiac surgery (PCS) determines treatment decision and long-term outcomes in patients requiring aortic valve replacement. This study examined patient profiles, treatment-decisions and long-term outcomes of patients under 75 years with PCS undergoing transcatheter and surgical aortic valve implantation/replacement (TAVI, SAVR) in the Netherlands. METHODS: Data from 1,284 patients (ages 50-75 years) with PCS undergoing TAVI or SAVR between 2015 and 2020 were analyzed using data from the Netherlands Heart Registration. Logistic and cox regression identified determinants of treatment selection and long-term mortality. Determinants were considered impactful if they had an odds ratio (OR) or hazard ratio (HR) of ≥ 1.5 or ≤ 0.7 and a prevalence of ≥ 5%. RESULTS: Of 1,284 patients, 690 underwent TAVI (54%) and 594 SAVR (46%). Prior index surgery most frequently involved coronary artery bypass grafting (CABG) (57% in the TAVI group vs 40% in the SAVR group; p < 0.001) and previous aortic valve surgery (25% vs 51%; p < 0.001). TAVI patients were significantly older (median 71 vs. 67 years, p < 0.001) and had a higher EuroSCORE II (median 5.7 vs. 4.4, p = 0.003) than SAVR patients. SAVR was the preferred strategy for intermediate-risk patients (62%), while TAVI was favored in high- and prohibitive-risk patients (62% and 94%, respectively). In descending order of odds ratio, the strongest independent determinants of TAVI selection were left ventricular ejection fraction ≤ 30% ((OR: 4.8; 95% CI: 2.6-8.8), poor mobility ((OR: 3.4; 95% CI: 1.6-7.0) and obesity/cachexia (OR 2.7; 95% CI: 1.6-4.4); the key determinants of SAVR selection were pure native aortic regurgitation (OR: 0.1; 95% CI: 0.1-0.3) and failing surgical bioprosthesis (OR: 0.7; 95% CI: 0.5-1.0. Thirty-day, 1- and 5 year survival after TAVI and SAVR was 97% and 96%, 83% and 91%, and 56% and 83%, respectively (p-value < 0.001). Left ventricular ejection fraction ≤ 30% and chronic lung disease were important mortality determinants for both procedures, with higher odds ratios for mortality in SAVR as compared to in TAVI patients. CONCLUSIONS: In the Netherlands, TAVI and SAVR rates were comparable among patients < 75 years with PCS. Higher-risk patients were directed toward TAVI except for those presenting with pure native aortic regurgitation and bioprosthesis failure who mainly received SAVR. Severe left ventricular dysfunction and chronic lung disease were key mortality predictors for both procedures.