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Although surgical aortic valve replacement (SAVR) has traditionally been the standard treatment, transfemoral transcatheter aortic valve replacement (TF-TAVR) is increasingly used. The optimal treatment for patients aged 60\u201375 remains debated.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This retrospective cohort study analyzed 28,805 German patients who underwent isolated SAVR or TF-TAVR (2018\u20132022). We applied double\/debiased machine learning estimators that combined adaptive lasso variable selection with propensity score\u2013based weighting across 21 baseline characteristics. Cost-effectiveness was assessed via incremental cost-effectiveness ratios (ICER) and cost-effectiveness acceptability curves from in-hospital and 1-year perspectives.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Compared with SAVR, TF-TAVR was associated with a significant reduction in in-hospital mortality (causal risk ratio [RR] 0.65;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.012), along with lower rates of bleeding (RR 0.29;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), postoperative delirium (RR 0.32;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001), and mechanical ventilation\u2009&gt;\u200948\u00a0h (RR 0.39;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). No significant difference was observed in acute kidney injury rates (RR 0.89;\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.150). However, reimbursement was substantially higher for TF-TAVR (\u20ac7071 more per case,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.001). A hypothetical shift from SAVR to TF-TAVR was associated with an ICER of \u20ac857,413 (95% CI \u20ac472,195\u2013\u20ac4,310,651) from the in-hospital perspective and \u20ac196,422 (95% CI \u20ac123,873\u2013\u20ac457,813) from the 1-year perspective. Notably, unadjusted analyses indicated a narrowing cost gap over time: Reimbursement for TF-TAVR decreased by approximately 12% between 2018 and 2022, while SAVR costs remained stable. Consequently, TF-TAVR is becoming increasingly cost-effective.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Given an estimated life expectancy of 11 to 25\u00a0years in this population, the incremental costs per life saved associated with a hypothetical shift from SAVR to TF-TAVR appear justifiable. Nonetheless, individual patient circumstances must always be considered in decision-making.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Graphical Abstract<\/jats:title>\n                  <\/jats:sec>","DOI":"10.1007\/s00392-026-02911-9","type":"journal-article","created":{"date-parts":[[2026,4,13]],"date-time":"2026-04-13T08:29:00Z","timestamp":1776068940000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["In-hospital outcomes and cost-effectiveness of transcatheter aortic valve replacement among younger patients: a double\/debiased machine learning approach using electronic health records in Germany"],"prefix":"10.1007","author":[{"given":"Klaus","family":"Kaier","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2767-8009","authenticated-orcid":false,"given":"Constantin","family":"von zur M\u00fchlen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Derek","family":"Hazard","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Adrian","family":"Heidenreich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Markus","family":"J\u00e4ckel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Vera","family":"Oettinger","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jonas","family":"Werner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manfred","family":"Zehender","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roman","family":"Gottardi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk","family":"Westermann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Valina","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,4,13]]},"reference":[{"key":"2911_CR1","doi-asserted-by":"publisher","first-page":"3006","DOI":"10.1161\/01.CIR.0000047200.36165.B8","volume":"106","author":"A Cribier","year":"2002","unstructured":"Cribier A, Eltchaninoff H, Bash A et al (2002) Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis: first human case description. 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