Adult: Aortic Valve| Volume 161, ISSUE 4, P1204-1210.e7, April 2021

The impact of surgical aortic valve replacement on quality of life—a multicenter study

Published:October 30, 2019DOI:



      To explore the effect of surgical aortic valve replacement on quality of life and the variance with age, particularly in patients at risk of deterioration.


      In an observational, multicenter, cohort study of routinely collected health data, patients undergoing and electively operated between January 2011 and January 2015 with pre- and postoperative quality of life data were included. Patients were classified into 3 age groups: <65, 65-79, and ≥80 years. Quality of life was measured at baseline and at 1-year follow-up using the Short-Form Health Survey-12 or SF-36. We defined a >5-point difference as a minimal clinically important difference. Multivariable linear regression analysis, with adjustment for confounders, was used to evaluate the association between age and quality of life.


      In 899 patients, mean physical health increased from 55 to 66 and mental health from 60 to 66. A minimal clinically important decreased physical health was observed in 12% of patients aged <65 years, 16% of patients aged 65-79 years, and 22% of patients aged ≥80 years (P = .023). A decreased mental health was observed in 15% of patients aged <65 years, 22% of patients aged 65-79 years, and 24% aged ≥80 years (P = .030). Older age and a greater physical and mental score at baseline were associated with a decreased physical and mental quality of life (P < .001).


      Patients surviving surgical aortic valve replacement on average improve in physical and mental quality of life; nonetheless, with increasing age patients are at higher risk of experiencing a deterioration.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AS (aortic valve stenosis), MCID (minimal clinically important difference), MCS (mental component summary score), PCS (physical component summary score), QoL (quality of life), SAVR (surgical aortic valve replacement), TAVR (transcatheter aortic valve replacement)
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        • Carabello B.A.
        • Paulus W.J.
        Aortic stenosis.
        Lancet. 2009; 373: 956-966
        • Brown J.M.
        • O'Brien S.M.
        • Wu C.
        • Sikora J.A.H.
        • Griffith B.P.
        • Gammie J.S.
        Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons national database.
        J Thorac Cardiovasc Surg. 2009; 137: 82-90
        • Eveborn G.W.
        • Schirmer H.
        • Heggelund G.
        • Lunde P.
        • Rasmussen K.
        The evolving epidemiology of valvular aortic stenosis. the Tromsø Study.
        Heart. 2013; 99: 396-400
        • Kodali S.K.
        • Williams M.R.
        • Smith C.R.
        • Svensson L.G.
        • Webb J.G.
        • Makkar R.R.
        • et al.
        Two-year outcomes after transcatheter or surgical aortic-valve replacement.
        N Engl J Med. 2012; 366: 1686-1695
        • Bonow R.O.
        • Brown A.S.
        • Gillam L.D.
        • Kapadia S.R.
        • Kavinsky C.J.
        • Lindman B.R.
        • et al.
        ACC/AATS/AHA/ASE/EACTS/HVS/SCA/SCAI/SCCT/SCMR/STS 2017 appropriate use criteria for the treatment of patients with severe aortic stenosis.
        J Am Coll Cardiol. 2017; 70: 2566-2598
        • Shan L.
        • Saxena A.
        • McMahon R.
        A systematic review on the quality of life benefits after aortic valve replacement in the elderly.
        Cardiology. 2014; 129: 46-54
        • Abah U.
        • Dunne M.
        • Cook A.
        • Hoole S.
        • Brayne C.
        • Vale L.
        • et al.
        Does quality of life improve in octogenarians following cardiac surgery? A systematic review.
        BMJ Open. 2015; 5: e006904
        • Gjeilo K.H.
        • Stenseth R.
        • Wahba A.
        • Lydersen S.
        • Klepstad P.
        Long-term health-related quality of life and survival after cardiac surgery: a prospective study.
        J Thorac Cardiovasc Surg. 2018; 156: 2183-2190
        • Blokzijl F.
        • Houterman S.
        • van Straten B.H.M.
        • Daeter E.
        • Brandon Bravo Bruinsma G.J.
        • Dieperink W.
        • et al.
        Quality of life after coronary bypass: a multicentre study of routinely collected health data in the Netherlands.
        Eur J CardioThoracic Surg. 2019; 56: 526-533
        • Benchimol E.I.
        • Smeeth L.
        • Guttmann A.
        • Harron K.
        • Moher D.
        The REporting of studies Conducted using Observational Routinely-collected health Data (RECORD) statement.
        PLoS Med. 2015; 12: e1001885
        • van Veghel D.
        • Marteijn M.
        • de Mol B.
        First results of a national initiative to enable quality improvement of cardiovascular care by transparently reporting on patient-relevant outcomes.
        Eur J Cardiothorac Surg. 2016; 49: 1660-1669
        • Stichting Meetbaar Beter
        Meetbaar Beter Boek 2015. Math Made, D&B Communicatie en Drukkerij Snep.
        (1-174. Available at:) (Accessed January 18, 2019)
        • Projectgroep BHN Registratieproject
        Handboek BHN registratieproject v4.01.
        Afdeling Klinische Informatiekunde, AMC Amsterdam2015
        • Stevens P.E.
        • Levin A.
        Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline.
        Ann Intern Med. 2013; 6: 825-830
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • Afilalo J.
        • Armstrong A.
        • Ernande L.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2015; 16: 233-271
        • Ware J.E.J.
        • Sherbourne C.D.
        The MOS 36-ltem short-form health survey (SF-36): I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • Müller-Nordhorn J.
        • Roll S.
        • Willich S.
        Comparison of the short form (SF)-12 health status instrument with the SF-36 in patients with coronary heart disease.
        Heart. 2004; 90: 523-527
        • Stichting Meetbaar Beter
        Meetbaar Beter Boek 2016. Math Made, D&B Communicatie en Drukkerij Snep.
        (1-174. Available at:) (Accessed January 18, 2019)
        • Projectgroep BHN Registratieproject
        BHN Registratieproject Handboek v4.0.
        Afdeling Klinische Informatiekunde, AMC Amsterdam2014
        • Sacco R.L.
        • Kasner S.E.
        • Broderick J.P.
        • Caplan L.R.
        • Connors J.J.
        • Culebras A.
        • et al.
        An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
        Stroke. 2013; 44: 2064-2089
        • Auensen A.
        • Hussain A.I.
        • Garratt A.M.
        • Gullestad L.L.
        • Pettersen K.I.
        Patient-reported outcomes after referral for possible valve replacement in patients with severe aortic stenosis.
        Eur J Cardiothorac Surg. 2018; 53: 129-135
        • Baumgartner H.
        • Falk V.
        • Bax J.J.
        • De Bonis M.
        • Hamm C.
        • Holm P.J.
        • et al.
        2017 ESC/EACTS guidelines for the management of valvular heart disease.
        Eur Heart J. 2017; 38: 2739-2786
        • Lytvyn L.
        • Guyatt G.H.
        • Manja V.
        • Siemieniuk R.A.
        • Zhang Y.
        • Agoritsas T.
        • et al.
        Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review.
        BMJ Open. 2016; 6: e014327
        • Indraratna P.
        • Ang S.C.
        • Gada H.
        • Yan T.D.
        • Manganas C.
        • Bannon P.
        • et al.
        Systematic review of the cost-effectiveness of transcatheter aortic valve implantation.
        J Thorac Cardiovasc Surg. 2014; 148: 509-514
        • Mack M.J.
        • Leon M.B.
        • Smith C.R.
        • Miller D.C.
        • Moses J.W.
        • Tuzcu E.M.
        • et al.
        5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial.
        Lancet. 2015; 385: 2477-2484
        • Baron S.J.
        • Arnold S.V.
        • Wang K.
        • Magnuson E.A.
        • Chinnakondepali K.
        • Makkar R.
        • et al.
        Health status benefits of transcatheter vs surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk.
        JAMA Cardiol. 2017; 2: 837-845
        • Mack M.J.
        • Leon M.B.
        • Thourani V.H.
        • Makkar R.
        • Kodali S.K.
        • Russo M.
        • et al.
        Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.
        N Engl J Med. 2019; 380: 1695-1705
        • Kurfirst V.
        • Mokráček A.
        • Krupauerová M.
        • Canádyová J.
        • Bulava A.
        • Pešl L.
        • et al.
        Health-related quality of life after cardiac surgery—the effects of age, preoperative conditions and postoperative complications.
        J Cardiothorac Surg. 2014; 9: 46
        • Jokinen J.J.
        • Hippelainen M.J.
        • Hanninen T.
        • Turpeinen A.K.
        • Hartikainen J.E.K.
        Prospective assessment of quality of life of octogenarians after cardiac surgery: factors predicting long-term outcome.
        Interact Cardiovasc Thorac Surg. 2008; 7: 813-818
        • Jansen Klomp W.W.
        • Nierich A.P.
        • Peelen L.M.
        • Brandon Bravo Bruinsma G.J.
        • Dambrink J.-H.E.
        • Moons K.G.M.
        • et al.
        Survival and quality of life after surgical aortic valve replacement in octogenarians.
        J Cardiothorac Surg. 2016; 11: 38
        • Van Laar C.
        • Kievit P.C.
        • Noyez L.
        Surgical aortic valve replacement in patients older than 75 years: is there really a quality of life benefit?.
        Neth Heart J. 2015; 23: 174-179
        • Centraal Bureau voor de Statistiek
        Gezondheid, aandoeningen, beperkingen; leeftijd en geslacht, 2010-2013.
        (Available at:) (Accessed May 19, 2018)
        • Noyez L.
        Is quality of life post cardiac surgery overestimated?.
        Health Qual Life Outcomes. 2014; 12: 2-7

      Linked Article

      • Commentary: Quality of life following aortic valve replacement in era of transcatheter approach: Change of time
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 4
        • Preview
          With increasing life expectancy and the upward tick of aging in the populations of Western countries, aortic valve stenosis has become one of the most common structural heart valvular diseases, and the incidence of aortic valve stenosis is increasing. An estimated 4.2 to 5.6 million adults in the United States have some form of clinically important valve disease.1
        • Full-Text
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      • Commentary: Age is just an element of the quality of life puzzle following aortic valve replacement
        The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 4
        • Preview
          In the current issue of the Journal, Blokzijl and colleagues1 reported the impact of surgical aortic valve replacement (SAVR) on physical and mental quality of life in 899 patients. The association between age and health-related quality of life (HRQL) was explored, and, as expected, older patients were identified the most at risk of experiencing deterioration. The authors’ analysis might be biased by the large number of nonrespondents (29% of patients), the merging of the Short Form-12 and Short Form-36 health status instrument values, and the relatively low-risk profile of these patients.
        • Full-Text
        • PDF