Transcatheter Aortic Valve Implantation in Patients Under Seventy: Durability, Reintervention and Lifetime Management
DOI:
https://doi.org/10.5281/zenodo.22344697Keywords:
Transcatheter aortic valve implantation, Valve durability, Lifetime management, Reintervention, Coronary accessAbstract
Transcatheter aortic valve implantation (TAVI) has moved from prohibitive-risk to low-risk patients on the strength of
randomised trials showing outcomes comparable to, or in some measures better than, surgical aortic valve replacement
(SAVR) through five to ten years: PARTNER 3 found similar clinical event rates and valve durability at seven years, Evolut
Low Risk found numerically fewer deaths with TAVI at four years, and NOTION found significantly less severe structural
valve deterioration with TAVI at ten years. This evidence has encouraged extending TAVI to patients well under 70, but the
trials underpinning it enrolled patients with a mean age of 73 to 74 years -- older, on average, than the population now
increasingly being treated. NOTION-2, the first randomised trial built specifically around patients aged 70 or younger, tells a
less reassuring story: at one year its composite endpoint numerically favoured surgery (10.2% TAVI versus 7.1% SAVR),
driven substantially by a stroke signal and, at three years, by a widening gap in patients with bicuspid aortic valves (20.4%
versus 7.8%) -- a valve morphology disproportionately common in exactly the younger population this review addresses.
Beyond individual trial results, the lifetime management literature estimates that roughly 20% of TAVI recipients will need at
least one reintervention within their lifetime, and a dedicated imaging study found that redo TAVI leaves over half of patients
with some degree of impaired future coronary access -- rising to an odds ratio of 19.8 with supra-annular valve designs -- a
consideration that matters far more for a 60-year-old with several decades of remaining life than for the 80-year-old such
valves were originally designed to treat. This review sets out the evidence for TAVI's expansion into younger patients and
closes with the complication that evidence has not yet fully resolved: choosing a valve and an implantation strategy today that
will not foreclose safe options decades from now.
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