Between 2016 and 2024, TAVR use peaked at 40.8% in 2020, coinciding with the COVID-19 pandemic. Thereafter, its use declined and stabilized at approximately 32.5% in 2024, accounting for roughly one-third of isolated aortic valve replacements in this population. However, as a spoiler, the authors report a marked increase in TAVR use over the study period, which they quantified as 360%. This increase occurred temporally after TAVR was approved for patients at low surgical risk in 2019, although the observational design of the study precludes establishing a direct causal relationship.

Patients selected for TAVR were, on average, older and had greater frailty and a higher prevalence of several comorbidities. These differences suggest that TAVR was preferentially selected for potentially more vulnerable patients, those at higher surgical risk, or those with a more limited life expectancy. However, the authors note that although approximately half of the patients treated with TAVR had characteristics that might support this treatment choice, no clear clinical rationale could be identified from the available data in the remaining half. This does not necessarily imply that TAVR was inappropriately indicated, but rather that the database lacked sufficient clinical information to adequately assess the decision.

In the unadjusted analysis, patients undergoing TAVR had a similar incidence of stroke compared with those undergoing SAVR, as well as lower rates of in-hospital and 30-day mortality, although the absolute differences were small. TAVR was also associated with a shorter hospital stay, a lower incidence of acute kidney injury, and less bleeding. Conversely, it was associated with a higher rate of pacemaker implantation, more vascular complications, and slightly higher hospital costs. These findings should be interpreted as descriptive associations rather than evidence of TAVR superiority, given the retrospective nature of the study, baseline differences between groups, and the absence of an adjusted comparative effectiveness analysis.

Furthermore, 12.3% of the hospitals included in the study performed TAVR in more than half of all isolated aortic valve replacements in younger patients. These institutions were more frequently high-volume TAVR centers and, to a lesser extent, teaching hospitals and large hospitals, defined as those with more than 499 beds.

In contrast, the use of mechanical SAVR remained stable and relatively low, ranging from approximately 15% to 19%, despite the fact that a substantial proportion of patients were young and could have a long life expectancy. This finding is particularly relevant in the context of lifetime valve management and observational evidence suggesting a potential survival advantage of mechanical prostheses over surgical bioprostheses in selected younger patient populations.

In conclusion, this study does not demonstrate that TAVR is a superior strategy in younger patients. Its main contribution is to show that TAVR use has expanded substantially and, after peaking in 2020, has stabilized at approximately one-third of isolated aortic valve replacements performed in patients aged 40 to 65 years. Although many patients treated with TAVR were more frail and had a greater burden of comorbidities, the lack of detailed clinical, anatomical, and prognostic information prevents determination of how many procedures were fully justified. The high use of TAVR and the limited use of mechanical prostheses raise important questions regarding patient selection, adherence to recommendations, and lifetime valve treatment planning.

COMMENTARY:

A progressive increase in TAVR use among younger patients, particularly those younger than 60 years, has been observed in the United States. This trend has also been reported in studies by Sharma et al. and Alabbadi et al., which showed that TAVR use increased to account for approximately 50% of aortic valve replacements performed in 2021. This figure is broadly consistent with the findings of the present study, in which TAVR use reached a peak of approximately 40% in 2020.

This trend may have begun, or at least accelerated, after TAVR was approved for patients at low surgical risk in 2019. This approval followed the results of two landmark randomized trials, PARTNER 3 and EVOLUT Low Risk. Nevertheless, TAVR has continued to expand despite American and European guideline recommendations favoring SAVR in patients younger than 65 and 70 years, respectively. These recommendations are based on the limited evidence regarding long-term TAVR outcomes, the relatively small number of younger patients enrolled in comparative studies of TAVR and SAVR, and the excellent outcomes achieved with SAVR in this population.

Both PARTNER 3 and the EVOLUT Low Risk Trial have reported favorable short- and mid-term outcomes in patients at low surgical risk, including similar mortality after TAVR and SAVR at four and five years of follow-up. In contrast, studies such as that by Alabbadi et al. have reported up to a twofold increase in the risk of mid-term mortality at six years among patients younger than 65 years undergoing TAVR. Similarly, Jishu et al. found lower mortality at one and five years among patients undergoing SAVR compared with those treated with TAVR in a population younger than 60 years.

The poorer survival observed after TAVR may be related to a higher risk of postoperative conduction disturbances, patient-prosthesis mismatch during subsequent percutaneous valve-in-valve procedures, and paravalvular leak compared with SAVR. These events have previously been identified as independent factors affecting survival. Likewise, the higher rate of pacemaker implantation after TAVR compared with SAVR may adversely affect functional status and long-term survival in patients at low surgical risk, as permanent pacing can impair left ventricular function and increase the risk of heart failure and mortality.

Differences in mortality outcomes may be explained, at least in part, by the stringent selection criteria applied in randomized clinical trials, whose study populations may not adequately represent patients encountered in routine clinical practice. Furthermore, the relatively small number of younger patients enrolled in these trials may limit their statistical power to detect differences in outcomes, as described by Jacquemyn et al.

Regarding other clinical outcomes, including neurological events, reintervention rates, residual aortic regurgitation, hospitalization for heart failure, and bleeding, the available results remain heterogeneous. Some studies have found no significant differences, whereas others have reported a higher incidence of adverse events after TAVR. One example is the EVOLUT Low Risk Trial subanalysis by Forrest et al., which reported a higher rate of reintervention at six years after TAVR, associated with a greater incidence of residual aortic regurgitation compared with SAVR.

Jishu et al. also reported a lower reintervention rate after SAVR than after TAVR. The authors suggested that this finding may be explained by the ability of surgery to achieve complete decalcification of the aortic annulus and root, potentially reducing the risk of paravalvular leak and, consequently, the need for subsequent reintervention.

This issue has important implications for survival, particularly as the number of procedures performed after an initial TAVR continues to increase. Specifically, both SAVR after TAVR and redo-TAVR have been associated with a higher risk of mortality compared with redo-SAVR. These findings highlight the importance of considering structural cardiac anatomy and anticipating potential future interventions when selecting the initial treatment strategy.

Finally, the article emphasizes the low use of mechanical prostheses in this younger population, which remained between approximately 15% and 19%. This finding is striking because a substantial proportion of these patients may have a long life expectancy, and current guideline recommendations are supported, among other considerations, by recent observational data associating mechanical prostheses with better survival than surgical bioprostheses in patients aged 60 years or younger. In this context, Bowdish et al. reported what is considered one of the largest observational analyses to date comparing bioprosthetic and mechanical valves for aortic valve replacement.

In conclusion, the increasing use of TAVR in younger patients requires its favorable early outcomes to be considered within a lifetime treatment strategy. However, the debate should not be restricted to TAVR versus SAVR, because controversy also persists within surgical treatment regarding the choice between bioprosthetic and mechanical valves, particularly given the potential survival advantage of mechanical prostheses in selected younger patients. Thus, the key question is not simply which approach is less invasive, but rather which prosthesis provides the best balance between early procedural risk, durability, need for reintervention, long-term survival, and the requirement for lifelong anticoagulation. In this setting, it is reasonable to ask: does it make sense to focus the debate on TAVR versus open surgery in patients younger than 65 years when the optimal choice between bioprosthetic and mechanical valves within surgery itself remains unresolved?

REFERENCE:

Mehaffey JH, Jagadeesan V, Hayanga JW, Chauhan D, Wei L, Mascio CE, et al. Trends of Aortic Valve Replacement in Patients 65 Years and Younger in the United States. Ann Thorac Surg. 2026 Jul;122(1):67-73. doi: 10.1016/j.athoracsur.2026.01.031. Epub 2026 Feb 6. PMID: 41655936; PMCID: PMC13455716.