Background:. Trancatheter aortic valve replacement (TAVR) is the most common approach in elderly patients suffering from aortic valve stenosis. Two recent randomized trials showed the 1-year efficiacy of TAVR compared to surgical aortic vavle replacement (SAVR) in younger low-risk patients. The present study analyzes decision making and outcomes of those patients in clinical practice. 

Methods: All aortic valve replacements in patients aged between 60 and 75 years from 2008 to 2019 in Germany reported via the diagnosis related groups to the nationwide registry has been identified. In a next step we focused on the different techniques of replacement in the years 2018 and 2019. A multivariate logistic regression analysis has been performed to adjust the patients risk factors in the outcome endpoints.

Results: In the years 2008 to 2019, 48,577  SAVR and 12,061 transfemoral TAVR (TF-TAVR) has been implemented in patients aged between 60 and 75 years. The amount of transfemoral TAVR increased from 2.7% in 2008 to 40% in 2019.

In 2018 and 2019 60% of all 11,161 patients in this group underwent SAVR, compared to 18.6% with balloon-expandable TF-TAVR, 16.8% with self-expanding TF-TAVR and 4.6% with transapical TAVR.

In a risk-adjusted multivariate logistic regression analysis the in-hospital mortality was significantly lower for balloon-expandable TF-TAVR (OR 0.52; 95% CI: 0.34 to 0.79; p=0.002) compared to SAVR. The rate of bleeding was significantly lower in all  TAVR: OR 0.48 for transapical AVR (95% CI: 0.32 to 0.71; p < 0.001); OR 0.25 for balloon-expandable TF-TAVR (95% CI: 0.19 to 0.34; p < 0.001) and OR 0.24 for self-expanding TF-TAVR (95% CI: 0.18 to 0.32; p < 0.001). The risk of stroke was lower in the TF-TAVR with balloon-expandable technique (OR 0.61; CI: 0.38 to 0.97; p = 0.04) compared to SAVR. Patients undergoing TF-TAVR had a smaller risk of acute kidney injury (OR 0.72; 95% CI: 0.58 to 0.88; p = 0.002 for balloon-expandable TAVR and OR 0.68; 95% CI: 0.54 to 0.85; p = 0.001 for self-expanding TAVR). Delir occurs in fewer patients after TF-TAVR compared to SAVR (OR 0.26; 95% CI: 0.2 to 0.33; p < 0.001 in balloon-expandable TAVR; OR 0.3; 95% CI: 0.24 to 0.38; p < 0.001 in self-expanding TAVR).

Conclusion: Transcatheter aortic valve replacement has become more frequent in younger patients with an age between 60 and 75 years in the past decade. The technique of balloon-expandable TF-TAVR was associated with a lower in-hospital mortality, bleeding complications, stroke, acute kidney injury and delir compared to surgical AVR.