Trends in Utilization and Outcomes of Ross, Transcatheter, and Surgical Aortic Valve Replacement in Adults Younger Than 65 Years Old.

Abstract

Transcatheter aortic valve replacement (TAVR) use among patients aged <65 years has risen rapidly, coinciding with renewed interest in the Ross procedure for aortic stenosis. This observational cohort study evaluated temporal trends in Ross, TAVR, and surgical aortic valve replacement (SAVR) utilization and compared their 6-year outcomes in adults 18-64 years old. We used California and New York discharge data (2000-2025) to identify patients undergoing Ross, TAVR, mechanical (SAVR-mech), or biological SAVR (SAVR-bio). Multivariable time-to-event models assessed the 6-year risks of death, myocardial infarction, stroke, infective endocarditis (IE), reintervention, and pacemaker implantation. Ross utilization declined from 2.8% in 2000 to 0.9% in 2005, then rebounded to 2.8% by 2022. TAVR expanded rapidly after 2011, while SAVR-mech declined and SAVR-bio plateaued after 2017. Early mortality was low across all groups, and notably rare after the Ross procedure. Compared with SAVR-bio, the Ross procedure was associated with lower adjusted 6-year mortality (hazard ratio [HR], 0.42; 95%CI, 0.19-0.91) and stroke risk. The risk of isolated aortic valve reintervention and aortic and/or pulmonary valve reintervention was higher after Ross and SAVR-mech than SAVR-bio but remained lower after TAVR. TAVR was associated with higher mortality (HR, 1.48; 95% CI, 1.07-2.05), infective endocarditis, and heart failure hospitalization compared with SAVR-bio. SAVR-mech demonstrated comparable survival to SAVR-bio (HR, 0.96; 95% CI, 0.85-1.08) but higher risks of infective endocarditis, myocardial infarction, heart failure, and pacemaker implantation. Ross use in adults aged <65 years is rising and confers lower 6-year mortality rates than SAVR-bio or TAVR, supporting broader consideration for younger patients.