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Address for reprints: Edris A. F. Mahtab, MD, PhD, Department of Cardiothoracic Surgery, Erasmus Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
The study objective was to analyze temporal changes in baseline and procedural characteristics and long-term survival of patients undergoing surgical aortic valve replacement over a 30-year period.
Methods
A retrospective analysis of patients undergoing surgical aortic valve replacement between 1987 and 2016 in the Erasmus Medical Center (Rotterdam, The Netherlands) was conducted. Patient baseline and procedural characteristics were analyzed in periods according to the date of surgical aortic valve replacement (period A: 1987-1996; B: 1997-2006; C: 2007-2016). Survival status was determined using the Dutch National Death Registry. Relative survival was obtained by comparing the survival after surgical aortic valve replacement with the survival of the age-, sex-, and year-matched general population.
Results
Between 1987 and 2016, 4404 patients underwent SAVR. From period A to C, the mean age increased from 63.9 ± 11.2 years to 66.2 ± 12.3 years (P < .001), and the prevalence of diabetes mellitus, hypertension, hypercholesterolemia, previous myocardial infarction, and previous stroke at baseline increased (P values for trend for all < .001). The prevalence of concomitant procedures increased from 42.4% in period A to 48.3% in period C (P = .004). Bioprosthesis use increased significantly (18.8% in period A vs 67.1% in period C, P < .001). Mean survival after surgical aortic valve replacement was 13.8 years. Relative survival at 20 years in the overall cohort was 60.4% (95% confidence interval, 55.9-65.2) and 73.8% (95% confidence interval, 67.1-81.1) in patients undergoing isolated primary surgical aortic valve replacement.
Conclusions
Patient complexity has been continuously increasing over the last 30 years, yet long-term survival after surgical aortic valve replacement remains high compared with the age-, sex-, and year-matched general population.
In a large SAVR cohort, relative survival is close to 90% at 10 years. This excellent long-term result reinforces the role of SAVR, especially in younger low-risk patients with long life expectancy.
These excellent long-term results, especially in the younger low-risk patient population with long life expectancy and lower operative risk, reinforce the role of SAVR in the treatment of aortic valve disease and serve as a benchmark for future dedicated long-term TAVR studies.
See Commentaries on pages 1752 and 1753.
Invasive treatment of aortic valve disease has been continuously evolving since the first surgical aortic valve replacement (SAVR) was performed in the 1960s.
Technical and procedural refinements, continuous prosthesis development, and periprocedural care improvement resulted in a substantial improvement of SAVR outcomes over the last decades.
Attractive for its less invasiveness, TAVR quickly became an established treatment modality for patients with aortic stenosis (AS) having high or intermediate surgical risk.
2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
These results forecast a new era in treating aortic valvular pathology, when optimal treatment allocation will become increasingly important.
Detailed analysis of patient and procedural characteristics, especially long-term survival after SAVR, is inevitable for informed treatment decisions. This study aimed to assess the trends in patient and procedural characteristics and the long-term survival in SAVR in a high-volume tertiary center over the last 3 decades.
Materials and Methods
Study Design and Data Collection
Adult patients undergoing SAVR between 1987 and 2016 at the Erasmus Medical Center, Rotterdam, The Netherlands, were analyzed. Patients receiving bioprosthetic or mechanical aortic valve prosthesis with or without concomitant cardiac procedures were included. Patients aged less than 18 years and patients receiving valved conduits were excluded. Baseline and procedural characteristics were collected retrospectively from electronic medical records. Survival status was obtained through the Dutch National Death Registry.
This study was conducted according to the privacy policy of the Erasmus Medical Center and regulations for the appropriate use of data in patient-oriented research, which are based on international regulations, including the Declaration of Helsinki (Institutional MEC Number: MEC-2019-0721), and patient informed consent was waived. All the authors vouch for the validity of the data and adherence to the protocol.
End Points and Definitions
The primary end point was the differences in baseline and procedural characteristics in the overall and primary isolated SAVR cohort, in three 10-year time periods according to the date of SAVR (period A: 1987-1996; B: 1997-2006; C: 2007-2016). The survival in the overall and primary isolated SAVR cohort was analyzed and compared with the survival of the matched general population (relative survival). SAVR within 24 hours of establishing the indication was classified as urgent. SAVR after 24 hours was classified as (semi-) elective. Left ventricular function was classified as normal if the left ventricular ejection fraction (LVEF) was greater than 50%, as reduced if the LVEF was 30% to 50%, and as severely reduced if the LVEF was less than 30%, as measured or estimated by a trained echocardiographer. Low-, intermediate-, and high-risk patients are defined as logistic European System for Cardiac Operative Risk Evaluation of 10 or less, 10 to 20, and 20 or greater, respectively.
Statistical Analysis
Categorical variables are presented as numbers, percentages, or proportions and compared with the chi-square test or the Fisher exact test, where appropriate. Continuous variables are presented as means ± standard deviation or median with the interquartile range and compared with the 2-sample t test or Wilcoxon rank-sum test where appropriate. Patients were classified into 10-year time periods based on surgery date (period A: 1987-1996; period B: 1997-2006; period C: 2007-2016). Trend analysis was performed with the chi-square test for trend.
The relative survival can be used as an estimate of cause-specific mortality. It is defined as the ratio between the observed survival and the expected survival in the general population.
The Human Mortality Database is continuously updated and includes mortality data from the Netherlands up until 2016. Relative survival is estimated through the Ederer II method.
Data management and statistical analyses were performed using SPSS 25.0 (SPSS Inc, Chicago, Ill) and R software, version 3.5 (R Foundation, Vienna, Austria).
Results
Baseline Characteristics
Between 1987 and 2016, a total of 4404 patients underwent SAVR with a biological (n = 2301) or mechanical (n = 2103) valve prosthesis. No patients were lost to follow-up for survival, with a mean follow-up of 13.8 years. Mean age was 65.5 ± 12.1 years, and 38.2% (n = 1683) were female. A total of 46.3% (n = 2041) required concomitant procedures, and 5.6% (n = 247) had redo SAVR. The indication for operation was AS or combined AS and aortic regurgitation in most cases (83.9%). The most common comorbidities included hypertension (35.1%, n = 1545), atrial fibrillation (17.6%, n = 775), and diabetes mellitus (14.9%, n = 656). The median logistic European System for Cardiac Operative Risk Evaluation (available since 2003; n = 2605) was 5.0%, with 18.8% (n = 480) of the patients having a logistic European System for Cardiac Operative Risk Evaluation of 10% or greater and 6.0% (n = 153) having a logistic European System for Cardiac Operative Risk Evaluation of 20% or greater. Further baseline characteristics are shown in Table 1 for the overall cohort and in Tables E1 and E2 for the isolated SAVR and the SAVR with concomitant CABG cohort.
Table 1Baseline characteristics over three decades in the overall cohort
All patients (n = 4404)
Period A 1987-1996 (n = 911)
Period B 1997-2006 (n = 1627)
Period C 2007-2016 (n = 1866)
Chi-square P value
Age at operation, y (mean ± SD)
65.5 ± 12.1
63.9 ± 11.2
65.5 ± 12.3
66.2 ± 12.3
<.001
<40
180 (4.1)
33 (3.6)
67 (4.1)
80 (4.3)
.427
40-49
302 (6.8)
74 (8.1)
121 (7.4)
107 (5.6)
.006
50-59
649 (14.7)
157 (17.2)
239 (14.7)
253 (13.6)
.013
60-69
1330 (30.2)
326 (35.8)
448 (27.5)
556 (29.8)
.012
70-79
1641 (37.3)
297 (32.6)
641 (39.4)
703 (37.7)
.041
≥80
303 (6.9)
24 (2.6)
111 (6.8)
168 (9.0)
<.001
Female
1683 (38.2)
338 (37.1)
679 (41.7)
666 (35.7)
.134
Indication (n = 4370)
AS
2894 (66.2)
499 (55.4)
1086 (66.9)
1309 (70.9)
<.001
AR
771 (17.6)
163 (18.1)
277 (17.1)
331 (17.9)
.966
Combined AS + AR
705 (16.1)
239 (26.5)
260 (16.0)
206 (11.2)
<.001
Bicuspid aortic valve
697 (15.8)
234 (25.7)
255 (15.7)
208 (11.2)
<.001
Endocarditis
292 (6.6)
67 (7.4)
95 (5.8)
130 (7.0)
.983
Logistic euroSCORE (n = 2073)(median, IQR)
5.0 (2.9-8.4)
N/A
5.0 (2.7-8.1)
5.1 (2.9-8.4)
.188
≥10
480 (18.8)
127 (18.4)
353 (18.9)
.772
≥20
153 (6.0)
36 (5.2)
117 (6.3)
.320
Previous cardiac operation
553 (12.6)
146 (16.0)
200 (12.3)
207 (11.1)
<.001
SAVR
247 (5.6)
74 (8.1)
72 (4.4)
101 (5.4)
.023
Creatinine ≥2 mg/dL
132 (3.0)
25 (2.7)
36 (2.2)
71 (3.8)
.020
Previous hemodialysis
32 (0.7)
5 (0.5)
10 (0.6)
17 (0.9)
.240
Atrial fibrillation
775 (17.6)
160 (17.6)
258 (15.9)
357 (19.1)
.134
Diabetes mellitus
656 (14.9)
69 (7.6)
205 (12.6)
382 (20.5)
<.001
Cardiac decompensation
728 (16.5)
210 (23.1)
259 (15.9)
259 (13.9)
<.001
Hypertension
1545 (35.1)
186 (20.4)
456 (28.0)
903 (48.4)
<.001
Hypercholesterolemia
720 (16.3)
47 (5.2)
207 (12.7)
466 (25.0)
<.001
Previous myocardial infarction
507 (11.5)
92 (10.1)
178 (10.9)
237 (12.7)
.030
Previous PCI
306 (6.9)
27 (3.0)
82 (5.0)
197 (10.6)
<.001
COPD
455 (10.3)
72 (7.9)
157 (9.6)
226 (12.1)
<.001
History of cancer
314 (7.1)
27 (3.0)
111 (6.8)
176 (9.4)
<.001
History of stroke
398 (9.0)
45 (4.9)
132 (8.1)
221 (11.8)
<.001
Arterial disease
195 (4.4)
21 (2.3)
59 (3.6)
115 (6.2)
<.001
Peripheral
170 (3.9)
20 (2.2)
51 (3.1)
99 (5.3)
<.001
Carotid
32 (0.7)
1 (0.1)
12 (0.7)
19 (1.0)
.010
LVEF (n = 4026)
Good
3147 (78.2)
577 (77.4)
1185 (79.3)
1385 (77.5)
.771
Reduced
729 (18.1)
120 (16.1)
264 (17.7)
345 (19.3)
.046
Severely reduced
150 (3.3)
48 (6.4)
46 (3.1)
56 (3.1)
.001
Values are presented as n (%) or as mean ± SD or median (interquartile range) if otherwise stated. SD, Standard deviation; AS, aortic stenosis; AR, aortic regurgitation; euroSCORE, European System for Cardiac Operative Risk Evaluation; IQR, interquartile range; N/A, not available; SAVR, surgical aortic valve replacement; PCI, percutaneous coronary intervention; COPD, chronic obstructive pulmonary disease; LVEF, left ventricular ejection function.
wDuring the 30-year observation period, the annual number of patients undergoing SAVR per period increased, from an annual average of 91 in period A to 187 in period C (Figure 1). The mean age increased from 63.9 ± 11.2 years in period A to 66.2 ± 12.3 years in period C (P < .001). The proportion of patients aged 70 years or more increased from 35.2% in period A to 46.7% in period C (P < .001). Between periods A and C, the prevalence of diabetes mellitus in the study population increased from 7.6% to 20.5% (P < .001), hypercholesterolemia from 5.2% to 25.0% (P < .001), and chronic obstructive pulmonary disease from 7.9% to 12.1% (P < .001). The percentage of patients with previous cardiac operations (P < .001) and redo SAVR decreased (P = .023). Further changes in baseline characteristics are shown in Table 1 for the overall cohort and in Tables E1 and E2 for the primary isolated SAVR and the primary SAVR with concomitant CABG cohort.
Figure 1Age at operation and annual number of patients undergoing SAVR over 30 years. Over 30 years, the percentage of elderly patients and the annual number of patients undergoing SAVR increased considerably. Results are reported according to the time of SAVR (period A: 1987-1996; B: 1997-2006; C: 2007-2016). A, Annual average of patients undergoing SAVR, according to the type of surgery. Y-axis represents the absolute number of patients. B, Age distribution of patients at the time of SAVR. SAVR, Surgical aortic valve replacement; CABG, coronary artery bypass grafting.
Trends in Procedural Characteristics and Prosthesis Use
During the study period, 46.3% (n = 2041) of the SAVR patients underwent concomitant procedures (Table 2), with a significant increase from 42.4% in period A to 48.3% in period C (P = .004). Most commonly, concomitant CABG was performed (n = 1433, 32.5%). Among patients undergoing concomitant CABG, 41.2% (n = 590) had single-vessel disease and 58.8% (n = 843) had multiple-vessel disease. The proportion of patients requiring concomitant CABG for single-vessel disease remained constant during the 30-year observation period (P = .412). Patients with concomitant CABG were older compared with patients not requiring revascularization (70.1 ± 8.3 vs 65.0 ± 12.0; P < .001). From period A to period C, the incidence of concomitant tricuspid and aortic procedures increased. The proportion of patients receiving bioprosthetic valves increased significantly, from 18.8% in period A to 67.1% in period C (P < .001, Figure 2). Detailed trends regarding changes in procedural characteristics and concomitant procedures are provided in Table 2.
Table 2Procedural characteristics over three decades in the overall cohort
All patients (n = 4404)
Period A 1987-1996 (n = 911)
Period B 1997-2006 (n = 1627)
Period C 2007-2016 (n = 1866)
Chi-square P value
Urgency (n = 3763)
.640
(Semi-)elective (>24 h)
98.0
97.6
98.0
98.0
Urgent (<24 h)
2.0
2.4
2.0
2.0
Concomitant cardiac procedure
46.3
42.4
46.3
48.3
.004
CABG
32.5
32.8
34.0
31.1
.226
1VD
41.2
45.2
39.1
41.1
.412
2VD
29.2
30.4
30.0
27.7
.362
3VD
29.7
24.4
30.9
31.2
.060
MV procedure
10.5
10.0
10.4
10.9
.465
TV procedure
2.6
1.0
2.1
3.8
<.001
MV and TV procedure
1.8
0.9
1.5
2.6
.001
Ascending aorta/arch replacement
3.0
0.3
2.6
4.5
<.001
Prosthesis type
<.001
Mechanical
47.8
81.2
46.1
32.9
Biological
52.2
18.8
53.9
67.1
Prosthesis size
23.6 ± 2.4
23.9 ± 2.2
23.7 ± 2.5
23.3 ± 2.3
<.001
19
3.9
1.6
3.0
5.8
<.001
21
22.6
19.3
21.8
24.9
.001
23
32.7
34.3
31.6
32.9
.630
25
24.9
28.1
24.2
23.9
.029
27
12.1
12.6
13.2
10.9
.106
29
3.5
3.6
5.8
1.4
<.001
Values are presented as percentages. CABG, Coronary artery bypass grafting; VD, vessel disease; MV, mitral valve; TV, tricuspid valve.
Figure 2Mechanical and bioprosthetic valve use across 3 decades. Absolute number of bioprosthetic and mechanical valves implanted according to patient age and time of SAVR (period A: 1987-1996; B: 1997-2006; C: 2007-2016). Note the considerable increase in patients receiving bioprosthetic valves from period A to C and the decrease in mechanical valve use above the age of 65 years. The X-axis represents the age at SAVR.
The 30-day mortality in the overall cohort decreased from 2.7% in period A to 1.8% in period C (P = .003). The 30-day mortality across 3 decades decreased, nonsignificantly, from 1.9% to 0.9% (P = .190) for primary isolated SAVR, and from 4.1% to 3.0% (P = .384) for primary SAVR with CABG (Table E3). The 10-year survival was 59.8% in the overall cohort, 65.5% in the isolated SAVR cohort, and 51.1% in the SAVR with concomitant CABG group (Table 3).
Table 3Ten-year survival after primary surgical aortic valve replacement over three decades
10-y survival
All patients
Period A 1987-1996
Period B 1997-2006
Period C 2007-2016
P value
Overall cohort
59.9
61.8
58.7
60.5
.243
Isolated SAVR
65.5
66.9
63.7
67.2
.312
SAVR + CABG
51.1
54.9
49.3
50.3
.352
SAVR + MV procedure
64.4
65.1
59.3
70.2
.253
Isolated SAVR
≥70 y
48.8
49.7
47.5
50.2
.772
60-69 y
70.6
70.6
67.7
76.3
.323
50-59 y
81.3
76.4
80.9
85.6
.294
Mechanical
74.6
69.3
75.2
83.6
.001
Biological
55.7
56.6
53.6
58.7
.450
Female
66.7
66.7
65.7
66.8
.676
Male
64.6
67.0
62.0
67.8
.287
High-risk patients (LES ≥20)
40.0
N/A
45.5
30.6
.727
Intermediate-risk patients (LES 10-20)
47.3
N/A
42.2
54.2
.418
Low-risk patients (LES <10)
70.4
N/A
71.5
69.5
.671
SAVR with CABG
≥70 y
41.0
40.2
39.2
44.5
.447
60-69 y
61.3
63.7
59.9
59.8
.909
50-59 y
75.5
80.6
77.8
62.6
.293
Mechanical
57.9
55.4
62.3
54.4
.381
Biological
46.8
53.3
43.2
49.5
.124
Female
48.0
51.4
45.6
49.3
.700
Male
52.6
56.6
51.0
50.7
.484
High-risk patients (LES ≥20)
23.6
N/A
20.0
24.6
.814
Intermediate-risk patients (LES 10-20)
46.1
N/A
37.6
52.4
.322
Low-risk patients (LES <10)
55.2
N/A
58.2
52.2
.412
Values are presented as percentages. SAVR, Surgical aortic valve replacement; CABG, coronary artery bypass grafting; MV, mitral valve; LES, logistic European System for Cardiac Operative Risk Evaluation; N/A, not available.
From period A to C, 10-year survival did not change in the overall cohort and patients receiving isolated SAVR from 62.8% to 60.3% (P = .051) and 66.9% to 67.2%, respectively (Table 3). Further trends in 10-year survival in various subgroups are displayed in Table 3 and Figure E1, Figure E2, Figure E3. Further trends in survival are shown in Tables E4 and E5.
Relative Survival
In the overall cohort, relative survival at 1, 5, 10, and 20 years was 95.7% (confidence interval [CI], 95.0-96.5), 95.4% (CI, 94.1-96.8), 85.8% (CI, 83.5-88.1), and 60.4% (CI, 55.9-65.2), respectively (Figure 3). In the cohort undergoing primary isolated SAVR, the relative survival was 98.1% (CI, 97.3-99.0), 99.9% (CI, 98.3-101.6), 92.4% (CI, 89.4-95.6), and 73.8% (CI, 67.1-81.1) at 1, 5, 10, and 20 years, respectively (Figure 4). In patients undergoing primary SAVR with CABG, the relative survival was 94.8% (CI, 93.2-96.4), 94.3% (95% CI, 91.6-97.3), 83.4% (95% CI, 78.5-88.4), and 41.6% (95% CI, 33.4-52.0), at 1, 5, 10, and 20 years, respectively (Figure 5). Long-term actual and relative survivals in the overall cohort are shown in Figure 6.
Figure 3Long-term survival after SAVR. Actual survival of patients in the overall SAVR cohort (red line) and relative survival compared with the age-, gender-, and year-matched Dutch population (blue line). The relative survival after SAVR is approximately 85% at 10 and 60% at 20 years when compared with that of the matched general population.
Figure 4Long-term survival after primary isolated SAVR. Actual survival (red line) and relative survival compared with the age-, gender-, and year-matched population (blue line). Note the relative survival of 73.8% after primary isolated SAVR at 20 years.
Figure 5Long-term actual and relative survival after primary SAVR with concomitant CABG. Actual survival (red line) and relative survival compared with the age-, gender-, and year-matched population (blue line). Note the relative survival of 41.6% after SAVR with concomitant CABG at 20 years.
Figure 6Long-term actual and relative survivals in the overall cohort. Long-term survival after SAVR. Actual survival of patients in the overall SAVR cohort (red line) and relative survival compared with the age-, gender-, and year-matched Dutch population (blue line). Note the relative survival of 85.8% at 10 and 60.4% at 20 years, respectively.
In this study, although the age, frequency of comorbid conditions, and complexity of patients undergoing SAVR increased over a 30-year period, the trends in 10-year survival remained stable or improved. Relative survival after SAVR was 85.8% (CI, 83.5-88.1) at 10 years. In patients undergoing primary isolated SAVR, the relative survival was 92.4% (CI, 89.4-95.6) and 73.8% (CI, 67.1-81.1) at 10 and 20 years, respectively. These excellent long-term results reinforce the role of SAVR in the treatment of aortic valve disease, especially in the younger low-risk patient population with long life expectancy and lower operative risk.
In our cohort, we saw a continuous increase in the number of patients undergoing SAVR. This increase is parallel to the growing number of SAVRs performed annually in Europe and the United States over the last decades,
and is most likely a result of a combination of factors. The ageing of the population led to an increase in the prevalence of AS in the Western countries,
Of note, this trend might be halted by the growing use of TAVR in elderly patients, which can eventually lead to a decrease in the annual number of SAVRs, a recent trend already observed in some countries.
The increasing frequency of comorbidities in our patient population is in accordance with the previously described changes in the profile of patients undergoing cardiac surgery.
Decreasing significance of left ventricular dysfunction and reoperative surgery in predicting coronary artery bypass grafting-associated mortality: a twelve-year study.
The prevalence of diabetes mellitus, hypercholesterolemia, and hypertension has at least doubled during the 30-year observation period. Diabetes is associated with worse outcomes in patients undergoing cardiac surgery.
Further, 31.1% of the patients in this study underwent concomitant CABG. Hypercholesterolemia and hypertension are well known to be associated with coronary artery disease. Coronary artery disease is present in up to 40% of the patients with AS undergoing SAVR and in up to 50% in SAVR patients aged 70 years or more.
Patients with concomitant CABG reflect a population with more advanced heart disease and diminished life expectancy due to higher short- and long-term mortality compared with those undergoing isolated SAVR.
Prosthesis choice is an important element of treatment decisions in aortic valve disease. Both mechanical and bioprosthetic valves are associated with inherent risks.
Mechanical valves require lifelong anticoagulation associated with bleeding events, and bioprosthetic valves are prone to degeneration, necessitating a second intervention in the long term.
Additionally, the age profile of SAVR patients changed considerably, with an increasing number of elderly patients undergoing SAVR. These patients form the bulk of the contemporary SAVR population and received almost exclusively a bioprosthetic valve. Although the first randomized controlled trial comparing bioprosthetic and mechanical valves showed better survival in patients receiving mechanical valves,
Despite the increasing patient age and complexity, the 30-day mortality decreased or remained stable over the 30-year observation period in the different cohorts. This may reflect advances in surgical technique and perioperative care over the last decades.
Although long-term actual survival after SAVR is influenced by the competing risk of mortality due to other factors, relative survival provides a good estimate of the disease- and intervention-related risks, because it compares the survival of the investigated population with the survival of the matched general population.
described a 74.9% relative survival at 15 years in a large SAVR cohort. In our study, the relative survival after isolated SAVR was similar to that of the age-, sex-, and year-matched Dutch population at 5 years, greater than 90% at 10 years, indicating an excellent long-term result. However, the decrease afterward in relative survival is not negligible and emphasizes the impact of disease- and intervention-related hazards in the extended long term.
The growing use of TAVR challenges the traditional role of SAVR in the treatment of aortic valve stenosis. In the light of recent trial results, the elderly SAVR population might have overlapping indications for both TAVR and SAVR in the future.
In the current 5-year data regarding intermediate-risk patients with severe symptomatic aortic stenosis, there was no difference between the incidence of the composite end point of mortality and disabling stroke in patients receiving TAVR and SAVR, 47.9% and 43.4%, respectively.
The added value even translated to the low-risk population. Patients classified as low risk had noninferior outcomes regarding the composite end point of mortality and disabling stroke at 2 years of follow-up, 5.3% and 6.7% in TAVR and SAVR, respectively.
Further research regarding the long-term durability of TAVR and the use of TAVR in specific patient groups, such as patients with high anatomic risk, including bicuspid morphology, dilated aortic root, heavy annular calcification, and expected future coronary access, remain warranted. Regular formal heart team discussions are recommended by the clinical guidelines.
2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
These meetings allow for informed decisions in a multidisciplinary setting, where the preferred intervention can be discussed on the basis of the individual patient profile, local resources and expertise, and the evidence available on procedure-related risks and long-term results.
Treatment decision for transcatheter aortic valve implantation: the role of the heart team : Position statement paper of the Dutch Working Group of Transcatheter Heart Interventions.
The results presented are based on data from a single center in The Netherlands. As with all retrospective studies, inherent shortcomings related to data capture are present. In addition, our study evaluated only survival as a long-term clinical outcome, because other important clinical outcomes (eg, quality of life, structural valve dysfunction or valve-related thromboembolic, and bleeding events) were not captured in our database. The amount of patients with newer-generation valves such as sutureless valves is low, which might yield different outcomes. Other potential limitations include selective outcome reporting.
Conclusions
The present study demonstrates the patient-related changes over time in patients receiving SAVR and the excellent SAVR-related outcomes over the last 3 decades. Isolated SAVR has proven itself with excellent long-term relative survival (73.8% at 20 years in our study). The existing SAVR cohort overlaps with the expected future TAVR cohort; therefore, our findings may serve as a benchmark for future TAVR population studies.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Appendix E1
Figure E1Long-term survival after SAVR in the overall cohort according to period operated. Actual survival of patients in the overall SAVR cohort. Patients operated between 1987 and 1996 (period A) are shown with the red line; patients operated between 1997 and 2006 (period B) are shown with the blue line; and patients operated between 2007 and 2017 (period C) are shown with the orange line. Comparison within periods is done for 10 years of follow-up and shown as P value.
Figure E2Long-term survival after primary isolated SAVR according to period operated. Actual survival of patients with primary isolated SAVR. Patients operated between 1987 and 1996 (period A) are shown with the red line; patients operated between 1997 and 2006 (period B) are shown with the blue line; and patients operated between 2007 and 2017 (period C) are shown with the orange line. Comparison within periods is done for 10 years of follow-up and shown as P value.
Figure E3Long-term actual after primary SAVR with concomitant CABG according to period operated. Actual survival of patients with primary SAVR and concomitant CABG. Patients operated between 1987 and 1996 (period A) are shown with the red line; patients operated between 1997 and 2006 (period B) are shown with the blue line; and patients operated between 2007 and 2017 (period C) are shown with the orange line. Comparison within periods is done for 10 years of follow-up and shown as P value.
Table E1Baseline and procedural characteristics over 3 decades in patients undergoing primary isolated surgical aortic valve replacement
All patients (n = 2198)
Period A 1987-1996 (n = 477)
Period B 1997-2006 (n = 827)
Period C 2007-2016 (n = 894)
Chi-square P value
Age at operation, y (mean ± SD)
65.0 ± 12.0
63.7 ± 10.7
65.1 ± 12.4
65.5 ± 12.3
.029
<40
3.6
2.9
3.9
3.8
.474
40-49
7.6
8.4
8.1
6.6
.188
50-59
15.8
16.8
15.5
15.7
.646
60-69
31.4
39.0
28.4
30.1
.004
70-79
35.0
31.0
36.9
35.3
.197
≥80
6.6
1.9
7.3
8.5
<.001
Female
41.1
38.8
45.6
38.1
.387
Indication (n = 2198)
AS
68.2
56.8
67.2
75.3
<.001
AR
13.5
13.2
14.6
12.6
.606
Combined
18.1
29.8
18.1
11.7
<.001
Bicuspid aortic valve
20.9
35.2
20.4
13.8
<.001
Endocarditis
5.4
4.8
4.5
6.5
.120
Logistic euroSCORE (n = 1239) (median, IQR)
4.2 (2.4-7.0)
N/A
4.2 (2.2-7.2)
4.2 (2.4-6.9)
.965
Logistic euroSCORE ≥10 n (%)
12.7
16.2
11.3
.019
Logistic euroSCORE ≥20 n (%)
3.0
3.2
2.9
.795
Previous cardiac operation
6.3
6.5
7.0
5.6
.400
Creatinine ≥2 mg/dL
2.3
2.1
1.9
2.7
.400
Previous hemodialysis
0.7
0.4
0.6
0.9
.287
Atrial fibrillation
12.9
13.8
13.3
12.1
.325
Diabetes mellitus
12.3
7.8
8.9
17.9
<.001
Cardiac decompensation
14.2
23.1
12.7
10.9
<.001
Hypertension
34.4
22.4
28.4
46.4
<.001
Hypercholesterolemia
15.2
5.0
12.3
23.3
<.001
Previous myocardial infarction
5.6
5.5
4.4
6.7
.187
Previous PCI
5.7
1.9
4.2
9.2
<.001
COPD
11.2
9.0
11.1
12.5
.051
History of cancer
6.7
2.1
7.3
8.7
<.001
Stroke
8.4
4.0
8.0
11.1
<.001
Arterial disease
3.0
1.0
2.5
4.5
<.001
Peripheral
2.6
1.0
2.3
3.8
.002
Carotid
0.5
0
0.4
0.8
.035
LVEF (n = 2006)
Good
81.8
78.4
82.8
82.4
.161
Reduced
14.9
15.1
14.7
14.8
.933
Severely reduced
3.3
6.5
2.5
2.8
.005
Urgency (n = 1942)
.910
(Semi-) Elective (>24 h)
98.7
98.6
1.3
1.3
Urgent (<24 h)
1.3
1.4
98.7
98.7
Prosthesis type
<.001
Mechanical
48.8
82.0
46.9
32.9
Bioprosthetic
51.2
18.0
53.1
67.1
Prosthesis size
23.6 ± 2.4
24.0 ± 2.3
24.0 ± 2.5
23.1 ± 2.3
<.001
19
3.9
1.5
2.3
6.7
<.001
21
22.5
17.9
20.7
26.7
<.001
23
32.0
32.8
30.7
32.7
.884
25
24.9
30.5
24.8
22.1
.001
27
11.9
12.2
13.9
10.0
.106
29
4.4
5.0
7.0
1.6
<.001
Values are presented as n (%) or as mean ± SD or median (interquartile range) if otherwise stated. SD, Standard deviation; AS, aortic stenosis; AR, aortic regurgitation; euroSCORE, European System for Cardiac Operative Risk Evaluation; IQR, interquartile range; N/A, not available; PCI, percutaneous coronary intervention; COPD, chronic obstructive pulmonary disease; LVEF, left ventricular ejection function.
Table E3Thirty-day mortality after primary surgical aortic valve replacement over 3 decades
30-d mortality
All patients
Period A 1987-1996
Period B 1997-2006
Period C 2007-2016
P value
Overall cohort
2.7 (4157)
2.7 (837)
3.7 (1555)
1.8 (1765)
.003
Isolated SAVR
1.5 (2198)
1.9 (477)
1.8 (827)
0.9 (894)
.190
SAVR + CABG
3.9 (1264)
4.1 (275)
4.7 (490)
3.0 (499)
.384
SAVR + MV procedure
4.8 (235)
3.8 (57)
7.7 (92)
2.3 (86)
.220
Isolated SAVR
≥70 y
2.5 (914)
3.8 (157)
3.0 (365)
1.5 (392)
.224
60-69 y
0.1 (690)
0.5 (186)
0 (235)
0 (269)
.258
50-59 y
1.7 (348)
2.5 (80)
1.6 (128)
1.4 (140)
.811
Mechanical
1.7 (1073)
2.1 (391)
2.1 (388)
0.7 (294)
.293
Biological
1.3 (1125)
1.2 (86)
1.6 (439)
1.0 (600)
.700
Female
1.3 (903)
2.2 (185)
1.9 (377)
0.3 (341)
.104
Male
1.5 (1295)
1.7 (292)
1.8 (450)
1.3 (553)
.776
High-risk patients (LES ≥20)
8.3 (37)
N/A
9.1 (11)
7.9 (26)
.936
Intermediate-risk patients (LES 10-20)
2.5 (120)
N/A
2.2 (45)
2.7 (75)
.873
Low-risk patients (LES <10)
0.7 (1082)
N/A
1.1 (289)
0.5 (793)
.302
SAVR with CABG
≥70 y
4.8 (738)
5.2 (137)
5.3 (300)
4.0 (301)
.719
60-69 y
2.7 (378)
3.2 (97)
3.9 (128)
1.3 (153)
.380
50-59 y
0.9 (116)
0 (36)
2.2 (46)
0 (34)
.467
Mechanical
4.6 (456)
4.9 (206)
4.5 (158)
4.3 (92)
.975
Biological
3.5 (808)
1.4 (69)
4.8 (332)
2.7 (407)
.184
Female
4.8 (380)
4.4 (92)
5.1 (157)
4.6 (131)
.957
Male
3.5 (884)
3.9 (183)
4.5 (333)
2.5 (368)
.325
High-risk patients (LES ≥20)
12.8 (39)
N/A
10.0 (10)
13.8 (29)
.742
Intermediate-risk patients (LES 10-20)
5.4 (94)
N/A
4.0 (25)
5.9 (69)
.725
Low-risk patients (LES <10)
2.1 (564)
N/A
3.1 (163)
1.8 (401)
.323
Values are given in percentages with (number of patients). SAVR, Surgical aortic valve replacement; CABG, coronary artery bypass grafting; MV, mitral valve; LES, logistic European System for Cardiac Operative Risk Evaluation; N/A, not available.
2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.
Decreasing significance of left ventricular dysfunction and reoperative surgery in predicting coronary artery bypass grafting-associated mortality: a twelve-year study.
Treatment decision for transcatheter aortic valve implantation: the role of the heart team : Position statement paper of the Dutch Working Group of Transcatheter Heart Interventions.
In this single-center retrospective study from the Netherlands, Çelik and colleagues1 report the outcomes over 3 decades of 4404 patients who underwent surgical aortic valve replacement (SAVR). The mean survival for the overall cohort was 13.8 years, and survival relative to an age-, sex-, and year-matched population was 85.8% and 60.4% for the overall cohort and 92.4% and 73.8% for the isolated SAVR cohort at 10 and 20 years, respectively. The authors argue that the latter 2 rates in particular should serve as benchmarks for future long-term transcatheter aortic valve replacement (TAVR) studies.
Aortic valve replacement (AVR) has been performed routinely since the appearance of the valve prostheses in the late 1960s and early 1970s.1 The procedure is now one of the most frequent, in some centers the most frequent, cardiac surgery performed, essentially due to the “epidemic” of aortic stenosis in elderly patients. More than 2 million patients may have had the procedure in the last half century. Despite the many types of prostheses created, some never used, the surgical procedure has remained essentially the same, but improvement in the management of cardiopulmonary bypass and of myocardial protection has made AVR very secure, with some groups claiming close-to-zero mortality rates.