Age-Stratified Surgical Aortic Valve Replacement for Aortic Stenosis

BACKGROUND:The management of aortic stenosis (AS) has evolved to stratification by age as reflected in recent societal guidelines. We evaluated age-stratified surgical aortic valve replacement (SAVR) trends and outcomes in patients with bicuspid (BAV) or tricuspid (TAV) aortic valves from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. METHODS:This cohort included adults (≥18 years) undergoing SAVR for severe AS between July 2011 and December 2022. Comparisons were stratified by age (<65, 65-79, ≥80 years) and BAV/TAV status. Primary endpoints included operative mortality, composite morbidity/mortality, and permanent stroke. Observed-to-expected (O/E) ratios by STS-predicted risk of mortality (PROM) were calculated. RESULTS:In total, 200,849 SAVR patients [55,326 BAV (27.5%), 145,526 TAV (72.5%)] from 1,238 participating hospitals met study criteria. Annual SAVR volumes decreased by 45% (19,560 to 10,851) over the study period. The decrease was greatest (96%) among patients ≥80 years of age (4,914 to 207). The relative prevalence of BAV was greater in younger patients [<65: 69,068 (49.5% BAV); 65-79: 104,382 (19.1% BAV); ≥80: 27,399 (4.5% BAV)]. The observed mortality in <80 years old BAV patients (<65: 1.08, 65-79: 1.21, ≥80: 3.68) was better than the expected mortality rate (<65: 1.22, 65-79: 1.54, ≥80: 3.14). CONCLUSIONS:SAVR volume in the transcatheter era has decreased substantially, particularly for patients ≥80 years old and for those with TAV. Younger patients with BAV have better-than-expected outcomes, which should be carefully considered during shared-decision making in the treatment of AS. SAVR should remain the preferred therapy in this population.