Surgical Aortic Valve Replacement with Y-incision Annular Enlargement Provided Better Hemodynamics and Early Survival than TAVR for Severe Aortic Stenosis

K. Monaghan¹, B. Yang^2
1Michigan Medicine, Ann Arbor, Michigan ²University of Michigan / Michigan Medicine, Ann Arbor, Michigan

Purpose: Recent trials suggested aortic stenosis patients treated with transcatheter aortic valve replacement (TAVR) had better hemodynamics and short-term survival than those treated with surgical aortic valve replacement (SAVR). We aimed to examine early outcomes of SAVR with Y-incision aortic annular enlargement (SAVR+AAE) versus TAVR in aortic stenosis patients.

Methods: From August 2020 to June 2023, 339 patients with severe aortic stenosis underwent either native TAVR or SAVR+AAE at our institution. Within this cohort, 64 underwent SAVR with Y-incision aortic annular enlargement (AAE). The SAVR valves used were bioprosthetic, Magna Ease (n=62) and Avalus (n=2). 275 patients underwent transcatheter aortic valve replacement (TAVR) with either the Sapien 3 (n=35) or the Evolut (n=240). Patients were propensity score matched with Age, Sex, body surface area (BSA), chronic lung disease, prior coronary artery bypass graft (CABG), ejection fraction (%), renal failure on dialysis, and patient status as covariates. We conducted 1:2 matching, reducing standard differences to moderate for all covariates apart from age. Mortality was analyzed with a Kaplan-Meier survival curve and Cox proportional-hazards model.

Results: In the SAVR+AAE group, the median annular enlargement was 3(3, 4) valve sizes and the median size of bioprosthetic valve implanted was 29(27, 29). Compared to the SAVR+AAE group, the TAVR group was significantly older (75 vs 68) and had higher STS risk scores (2.5 vs. 1.6, both were in the low-risk range). Other preoperative demographics including diabetes, prior stroke, COPD, and preoperative creatinine levels were similar. The operative mortality was similar between SAVR+AAE and TAVR groups, (0% vs. 0.78%, p=1.0). Early postoperative echocardiographic data measured 1-3 months after intervention showed the SAVR+AAE group had lower mean gradients across the aortic valve, 6(5, 8) mmHg compared to the TAVR group, 8(5, 11) mmHg, p=0.005. The 2-year survival was significantly higher in the SAVR+AAE group, 97% (95% CI: 82, 99) compared to the TAVR group, 78% (95% CI: 68, 86) (Figure, p=0.01). The hazard ratio for age was 0.98 (95% CI: 0.92, 1.1), p=0.43, female sex was 0.62 (95% CI: 0.26, 1.48), p=0.28, and chronic lung disease was 2.82 (95% CI: 1.1, 7.1), p=0.03. The hazard ratio for TAVR was 7.26 (95% CI: 0.93, 57), p=0.05, and STS risk score was 1.39 (95% CI: 1.2, 1.6), p< 0.0001.

Conclusion: SAVR with Y-incision AAE provided significantly better early survival and hemodynamics than the latest technology TAVR valves in patients with native aortic valve stenosis. SAVR + Y-incision AAE should be considered over TAVR for patients who are surgical candidates for intervention on native aortic valve stenosis.

Identify the source of the funding for this research project: NIH R01HL141891 and R01HL151776