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Outcomes of surgical aortic valve replacement over three decades

Open AccessPublished:April 27, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.04.064

      Abstract

      Objective

      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.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AS (aortic stenosis), CABG (coronary artery bypass grafting), CI (confidence interval), LVEF (left ventricular ejection fraction), SAVR (surgical aortic valve replacement), TAVR (transcatheter aortic valve replacement)
      Figure thumbnail fx2
      Long-term actual and relative survival after SAVR.
      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.
      • Effler D.B.
      • Favaloro R.
      • Groves L.K.
      Heart valve replacement. Clinical experience.
      Technical and procedural refinements, continuous prosthesis development, and periprocedural care improvement resulted in a substantial improvement of SAVR outcomes over the last decades.
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      • O'Brien S.M.
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      • Peterson E.D.
      • et al.
      Fifteen-year outcome trends for valve surgery in North America.
      Concurrently, patient characteristics have changed considerably, and the comorbidity burden is increasing.
      • Lee R.
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      • O'Brien S.M.
      • Gammie J.S.
      • Peterson E.D.
      • et al.
      Fifteen-year outcome trends for valve surgery in North America.
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      • Sheng S.
      • O’Brien S.M.
      • Ailawadi G.
      • et al.
      Contemporary real-world outcomes of surgical aortic valve replacement in 141,905 low-risk, intermediate-risk, and high-risk patients.
      The latest revolution in treating aortic valve replacement was the introduction of transcatheter aortic valve replacement (TAVR) in the early 2000s.
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      • et al.
      Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis.
      Attractive for its less invasiveness, TAVR quickly became an established treatment modality for patients with aortic stenosis (AS) having high or intermediate surgical risk.
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      • et al.
      2017 ESC/EACTS guidelines for the management of valvular heart disease.
      ,
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      • et al.
      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.
      More recently, clinical trial results have even challenged the role of SAVR in low-risk patients with AS.
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      • Russo M.
      • et al.
      Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.
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      Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.
      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.
      • Perme M.
      • Pavlic K.
      Nonparametric relative survival analysis with the R Package relsurv.
      The Human Mortality Database was used to obtain the age-, sex-, and year-matched expected survival data of the general population of The Netherlands.
      The Human Mortality Database.
      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.
      • Pohar M.
      • Stare J.
      Relative survival analysis in R.
      ,
      • Pohar M.
      • Stare J.
      Making relative survival analysis relatively easy.
      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 ± 12.163.9 ± 11.265.5 ± 12.366.2 ± 12.3<.001
       <40180 (4.1)33 (3.6)67 (4.1)80 (4.3).427
       40-49302 (6.8)74 (8.1)121 (7.4)107 (5.6).006
       50-59649 (14.7)157 (17.2)239 (14.7)253 (13.6).013
       60-691330 (30.2)326 (35.8)448 (27.5)556 (29.8).012
       70-791641 (37.3)297 (32.6)641 (39.4)703 (37.7).041
       ≥80303 (6.9)24 (2.6)111 (6.8)168 (9.0)<.001
      Female1683 (38.2)338 (37.1)679 (41.7)666 (35.7).134
      Indication (n = 4370)
       AS2894 (66.2)499 (55.4)1086 (66.9)1309 (70.9)<.001
       AR771 (17.6)163 (18.1)277 (17.1)331 (17.9).966
       Combined AS + AR705 (16.1)239 (26.5)260 (16.0)206 (11.2)<.001
      Bicuspid aortic valve697 (15.8)234 (25.7)255 (15.7)208 (11.2)<.001
      Endocarditis292 (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/A5.0 (2.7-8.1)5.1 (2.9-8.4).188
       ≥10480 (18.8)127 (18.4)353 (18.9).772
       ≥20153 (6.0)36 (5.2)117 (6.3).320
      Previous cardiac operation553 (12.6)146 (16.0)200 (12.3)207 (11.1)<.001
       SAVR247 (5.6)74 (8.1)72 (4.4)101 (5.4).023
      Creatinine ≥2 mg/dL132 (3.0)25 (2.7)36 (2.2)71 (3.8).020
      Previous hemodialysis32 (0.7)5 (0.5)10 (0.6)17 (0.9).240
      Atrial fibrillation775 (17.6)160 (17.6)258 (15.9)357 (19.1).134
      Diabetes mellitus656 (14.9)69 (7.6)205 (12.6)382 (20.5)<.001
      Cardiac decompensation728 (16.5)210 (23.1)259 (15.9)259 (13.9)<.001
      Hypertension1545 (35.1)186 (20.4)456 (28.0)903 (48.4)<.001
      Hypercholesterolemia720 (16.3)47 (5.2)207 (12.7)466 (25.0)<.001
      Previous myocardial infarction507 (11.5)92 (10.1)178 (10.9)237 (12.7).030
      Previous PCI306 (6.9)27 (3.0)82 (5.0)197 (10.6)<.001
      COPD455 (10.3)72 (7.9)157 (9.6)226 (12.1)<.001
      History of cancer314 (7.1)27 (3.0)111 (6.8)176 (9.4)<.001
      History of stroke398 (9.0)45 (4.9)132 (8.1)221 (11.8)<.001
      Arterial disease195 (4.4)21 (2.3)59 (3.6)115 (6.2)<.001
       Peripheral170 (3.9)20 (2.2)51 (3.1)99 (5.3)<.001
       Carotid32 (0.7)1 (0.1)12 (0.7)19 (1.0).010
      LVEF (n = 4026)
       Good3147 (78.2)577 (77.4)1185 (79.3)1385 (77.5).771
       Reduced729 (18.1)120 (16.1)264 (17.7)345 (19.3).046
       Severely reduced150 (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.

      Changes in Patient Profile Over Three Decades

      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 thumbnail gr1
      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)98.097.698.098.0
       Urgent (<24 h)2.02.42.02.0
      Concomitant cardiac procedure46.342.446.348.3.004
       CABG32.532.834.031.1.226
      1VD41.245.239.141.1.412
      2VD29.230.430.027.7.362
      3VD29.724.430.931.2.060
       MV procedure10.510.010.410.9.465
       TV procedure2.61.02.13.8<.001
       MV and TV procedure1.80.91.52.6.001
       Ascending aorta/arch replacement3.00.32.64.5<.001
      Prosthesis type<.001
       Mechanical47.881.246.132.9
       Biological52.218.853.967.1
      Prosthesis size23.6 ± 2.423.9 ± 2.223.7 ± 2.523.3 ± 2.3<.001
       193.91.63.05.8<.001
       2122.619.321.824.9.001
       2332.734.331.632.9.630
       2524.928.124.223.9.029
       2712.112.613.210.9.106
       293.53.65.81.4<.001
      Values are presented as percentages. CABG, Coronary artery bypass grafting; VD, vessel disease; MV, mitral valve; TV, tricuspid valve.
      Figure thumbnail gr2
      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.

      Trends in 30-Day Mortality and Long-Term Survival

      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 patientsPeriod A 1987-1996Period B 1997-2006Period C 2007-2016P value
      Overall cohort59.961.858.760.5.243
      Isolated SAVR65.566.963.767.2.312
      SAVR + CABG51.154.949.350.3.352
      SAVR + MV procedure64.465.159.370.2.253
      Isolated SAVR
       ≥70 y48.849.747.550.2.772
       60-69 y70.670.667.776.3.323
       50-59 y81.376.480.985.6.294
       Mechanical74.669.375.283.6.001
       Biological55.756.653.658.7.450
       Female66.766.765.766.8.676
       Male64.667.062.067.8.287
       High-risk patients (LES ≥20)40.0N/A45.530.6.727
       Intermediate-risk patients (LES 10-20)47.3N/A42.254.2.418
       Low-risk patients (LES <10)70.4N/A71.569.5.671
      SAVR with CABG
       ≥70 y41.040.239.244.5.447
       60-69 y61.363.759.959.8.909
       50-59 y75.580.677.862.6.293
       Mechanical57.955.462.354.4.381
       Biological46.853.343.249.5.124
       Female48.051.445.649.3.700
       Male52.656.651.050.7.484
       High-risk patients (LES ≥20)23.6N/A20.024.6.814
       Intermediate-risk patients (LES 10-20)46.1N/A37.652.4.322
       Low-risk patients (LES <10)55.2N/A58.252.2.412
      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 thumbnail gr3
      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 thumbnail gr4
      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 thumbnail gr5
      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 thumbnail gr6
      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.

      Discussion

      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,
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      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.
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      • Reul R.M.
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      • Pennington D.G.
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      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.
      • Sarfati D.
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      • Glaser N.
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      Loss in life expectancy after surgical aortic valve replacement: SWEDEHEART study.
      reported a relative survival of 97% and 88% at 5 and 10 years after SAVR, respectively, and Kvidal and colleagues
      • Kvidal P.
      • Bergstrom R.
      • Horte L.G.
      • Stahle E.
      Observed and relative survival after aortic valve replacement.
      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.
      • Glaser N.
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      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.
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      • et al.
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      ,
      • Popma J.J.
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      • et al.
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      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.
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      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.
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      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.
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      Study Limitations

      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 thumbnail fx3
      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 thumbnail fx4
      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 thumbnail fx5
      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 ± 12.063.7 ± 10.765.1 ± 12.465.5 ± 12.3.029
       <403.62.93.93.8.474
       40-497.68.48.16.6.188
       50-5915.816.815.515.7.646
       60-6931.439.028.430.1.004
       70-7935.031.036.935.3.197
       ≥806.61.97.38.5<.001
      Female41.138.845.638.1.387
      Indication (n = 2198)
       AS68.256.867.275.3<.001
       AR13.513.214.612.6.606
       Combined18.129.818.111.7<.001
      Bicuspid aortic valve20.935.220.413.8<.001
      Endocarditis5.44.84.56.5.120
      Logistic euroSCORE (n = 1239) (median, IQR)4.2 (2.4-7.0)N/A4.2 (2.2-7.2)4.2 (2.4-6.9).965
       Logistic euroSCORE ≥10 n (%)12.716.211.3.019
       Logistic euroSCORE ≥20 n (%)3.03.22.9.795
      Previous cardiac operation6.36.57.05.6.400
      Creatinine ≥2 mg/dL2.32.11.92.7.400
      Previous hemodialysis0.70.40.60.9.287
      Atrial fibrillation12.913.813.312.1.325
      Diabetes mellitus12.37.88.917.9<.001
      Cardiac decompensation14.223.112.710.9<.001
      Hypertension34.422.428.446.4<.001
      Hypercholesterolemia15.25.012.323.3<.001
      Previous myocardial infarction5.65.54.46.7.187
      Previous PCI5.71.94.29.2<.001
      COPD11.29.011.112.5.051
      History of cancer6.72.17.38.7<.001
      Stroke8.44.08.011.1<.001
      Arterial disease3.01.02.54.5<.001
       Peripheral2.61.02.33.8.002
       Carotid0.500.40.8.035
      LVEF (n = 2006)
       Good81.878.482.882.4.161
       Reduced14.915.114.714.8.933
       Severely reduced3.36.52.52.8.005
      Urgency (n = 1942).910
       (Semi-) Elective (>24 h)98.798.61.31.3
       Urgent (<24 h)1.31.498.798.7
      Prosthesis type<.001
       Mechanical48.882.046.932.9
       Bioprosthetic51.218.053.167.1
      Prosthesis size23.6 ± 2.424.0 ± 2.324.0 ± 2.523.1 ± 2.3<.001
       193.91.52.36.7<.001
       2122.517.920.726.7<.001
       2332.032.830.732.7.884
       2524.930.524.822.1.001
       2711.912.213.910.0.106
       294.45.07.01.6<.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 E2Baseline and procedural characteristics over three decades in patients undergoing isolated surgical aortic valve replacement + coronary artery bypass grafting
      All patients (n = 1264)Period A 1987-1996 (n = 275)Period B 1997-2006 (n = 490)Period C 2007-2016 (n = 499)Chi-square P value
      Age at operation, y (mean ± SD)70.1 ± 8.368.5 ± 8.070.0 ± 8.571.0 ± 8.2<.001
       40-492.51.83.32.2.938
       50-599.213.19.46.8.004
       60-6929.935.326.130.7.376
       70-7948.144.452.745.7.897
       ≥8010.35.58.614.6<.001
      Female30.133.532.026.3.023
      Indication (n = 1264)
       AS80.270.280.885.2<.001
       AR8.89.19.28.2.632
       Combined10.920.410.06.6<.001
      Bicuspid aortic valve10.519.39.07.2<.001
      Endocarditis1.52.21.61.0.186
      Logistic euroSCORE (n = 697) (median, IQR)5.3 (3.3-8.7)N/A5.5 (3.7-8.4)5.3 (3.2-8.9).977
       Logistic euroSCORE ≥10 n (%)19.117.719.6.552
       Logistic euroSCORE ≥20 n (%)5.65.15.8.694
      Previous cardiac operation5.58.76.32.8<.001
      Creatinine ≥2 mg/dL2.82.52.73.0.686
      Previous hemodialysis0.91.10.61.0.984
      Atrial fibrillation12.513.112.012.6.911
      Diabetes mellitus21.28.020.029.7<0.001
      Cardiac decompensation15.618.516.313.2.043
      Hypertension41.222.531.461.1<.001
      Hypercholesterolemia21.86.917.834.1<.001
      Previous myocardial infarction24.420.024.726.7.046
      Previous PCI10.25.87.315.4<.001
      COPD9.97.38.612.6.010
      History of cancer7.53.36.111.2<.001
      Stroke9.34.78.212.8<.001
      Arterial disease8.45.86.511.6.002
       Peripheral7.25.55.79.6.016
       Carotid1.50.41.42.2.044
      LVEF (n = 1185)
       Good75.775.876.874.5.589
       Reduced20.517.819.722.6.114
       Severely reduced3.86.43.52.9.033
      Urgency (n = 1104).536
       (Semi-) Elective (>24 h)98.699.498.598.5
       Urgent (<24 h)1.40.61.51.5
      Prosthesis type<.001
       Mechanical36.174.932.218.4
       Biological63.925.167.881.6
      Prosthesis size23.5 ± 2.223.6 ± 2.123.7 ± 2.323.2 ± 2.1.003
       193.82.22.46.0.003
       2121.620.021.822.2.495
       2335.538.934.534.7.296
       2526.324.724.928.7.181
       2710.912.713.57.4.008
       291.51.52.20.8.307
      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 patientsPeriod A 1987-1996Period B 1997-2006Period C 2007-2016P value
      Overall cohort2.7 (4157)2.7 (837)3.7 (1555)1.8 (1765).003
      Isolated SAVR1.5 (2198)1.9 (477)1.8 (827)0.9 (894).190
      SAVR + CABG3.9 (1264)4.1 (275)4.7 (490)3.0 (499).384
      SAVR + MV procedure4.8 (235)3.8 (57)7.7 (92)2.3 (86).220
      Isolated SAVR
       ≥70 y2.5 (914)3.8 (157)3.0 (365)1.5 (392).224
       60-69 y0.1 (690)0.5 (186)0 (235)0 (269).258
       50-59 y1.7 (348)2.5 (80)1.6 (128)1.4 (140).811
       Mechanical1.7 (1073)2.1 (391)2.1 (388)0.7 (294).293
       Biological1.3 (1125)1.2 (86)1.6 (439)1.0 (600).700
       Female1.3 (903)2.2 (185)1.9 (377)0.3 (341).104
       Male1.5 (1295)1.7 (292)1.8 (450)1.3 (553).776
       High-risk patients (LES ≥20)8.3 (37)N/A9.1 (11)7.9 (26).936
       Intermediate-risk patients (LES 10-20)2.5 (120)N/A2.2 (45)2.7 (75).873
       Low-risk patients (LES <10)0.7 (1082)N/A1.1 (289)0.5 (793).302
      SAVR with CABG
       ≥70 y4.8 (738)5.2 (137)5.3 (300)4.0 (301).719
       60-69 y2.7 (378)3.2 (97)3.9 (128)1.3 (153).380
       50-59 y0.9 (116)0 (36)2.2 (46)0 (34).467
       Mechanical4.6 (456)4.9 (206)4.5 (158)4.3 (92).975
       Biological3.5 (808)1.4 (69)4.8 (332)2.7 (407).184
       Female4.8 (380)4.4 (92)5.1 (157)4.6 (131).957
       Male3.5 (884)3.9 (183)4.5 (333)2.5 (368).325
       High-risk patients (LES ≥20)12.8 (39)N/A10.0 (10)13.8 (29).742
       Intermediate-risk patients (LES 10-20)5.4 (94)N/A4.0 (25)5.9 (69).725
       Low-risk patients (LES <10)2.1 (564)N/A3.1 (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.
      Table E41-y survival after primary surgical aortic valve replacement over 3 decades
      1-y survival
      All patientsPeriod A 1987-1996Period B 1997-2006Period C 2007-2016P value
      Overall cohort93.594.492.094.4.012
      Isolated SAVR95.795.794.796.6.154
      SAVR + CABG91.591.790.892.1.727
      SAVR + MV procedure89.994.383.294.1.026
      Isolated SAVR
       ≥70 y93.592.392.095.4.133
       60-69 y98.298.997.498.5.484
       50-59 y95.994.896.196.4.831
       Mechanical95.995.395.697.3.376
       Biological95.597.694.096.3.131
       Female95.994.594.698.2.027
       Male95.696.594.895.7.574
       High-risk patients (LES ≥20)89.0N/A90.988.1.797
       Intermediate-risk patients (LES 10-20)94.2N/A93.394.7.780
       Low-risk patients (LES <10)97.3N/A97.997.1.491
      SAVR with CABG
       ≥70 y89.489.388.390.6.639
       60-69 y94.193.693.794.7.913
       50-59 y96.697.297.894.1.647
       Mechanical91.390.593.090.2.659
       Biological91.695.689.792.6.185
       Female91.792.193.689.2.432
       Male91.591.689.593.2.215
       High-risk patients (LES ≥20)76.9N/A90.072.4.282
       Intermediate-risk patients (LES 10-20)89.2N/A91.888.3.628
       Low-risk patients (LES <10)94.1N/A93.894.2.841
      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 availableCABG, Coronary artery bypass grafting; LES, Logistic European System for Cardiac Operative Risk Evaluation; MV, mitral valve; N/A, not available; SAVR, surgical aortic valve replacement.
      Table E5Five-year survival after primary surgical aortic valve replacement over 3 decades
      5-y survival
      All patientsPeriod A 1987-1996Period B 1997-2006Period C 2007-2016P value
      Overall cohort82.484.580.982.9.059
      Isolated SAVR86.886.985.887.8.454
      SAVR + CABG77.579.775.378.4.301
      SAVR + MV procedure79.382.873.084.6.143
      Isolated SAVR
       ≥70 y81.279.980.382.6.624
       60-69 y89.691.487.889.8.471
       50-59 y91.486.991.394.0.210
       Mechanical89.787.289.293.9.019
       Biological84.085.682.984.7.618
       Female88.886.087.392.1.049
       Male85.587.484.685.1.546
       High-risk patients (LES ≥20)75.6N/A81.871.5.559
       Intermediate-risk patients (LES 10-20)78.7N/A80.078.0.766
       Low-risk patients (LES <10)89.1N/A89.089.2.928
      SAVR with CABG
       ≥70 y71.972.469.274.4.343
       60-69 y84.184.184.184.1>.999
       50-59 y90.394.488.987.4.596
       Mechanical81.280.283.279.7.716
       Biological75.378.371.578.1.097
       Female80.081.380.778.2.813
       Male76.479.072.778.5.120
       High-risk patients (LES ≥20)50.4N/A40.054.7.694
       Intermediate-risk patients (LES 10-20)73.1N/A66.875.3.431
       Low-risk patients (LES <10)81.0N/A81.380.8.947
      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.

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      Linked Article

      • Commentary: Our patients deserve our patience
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          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.
        • Full-Text
        • PDF
      • Commentary: Long-term outcomes of surgical aortic valve replacement: Difficult to match!
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          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.
        • Full-Text
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