Changing Surgical Aortic Valve Size and Choices in the Transcatheter Aortic Valve Replacement Era

Objective. The adoption of transcatheter aortic valve replacement (TAVR) has changed the profile of patients referred for surgical aortic valve replacement (SAVR) and drawn more attention to valve sizing and durability. We examined the influence of TAVR on SAVR practice. Methods. Using a statewide database, we evaluated all isolated SAVRs, categorized into three eras: pre-TAVR (2008 to 2011), early TAVR (2012 to 2015), and current-TAVR (2016 to 2022). The primary outcomes of interest were changes in prosthetic valve size and the percentage of mechanical valves used between time periods. Results. There were 6,445 patients included. SAVR volume declined in the current era. Valve size increased over time. In the pre-TAVR era, 41% of patients received a valve smaller than 23 mm, which declined to 33% in the early TAVR era, then to 22% in the current era ( <a:math xmlns:a="http://www.w3.org/1998/Math/MathML" id="M1"><a:mi>p</a:mi></a:math> < 0.001 for all). The year of surgery was significantly associated with larger valve selection even after controlling for patient characteristics. Annular enlargement rose in the current-TAVR era ( <c:math xmlns:c="http://www.w3.org/1998/Math/MathML" id="M2"><c:mi>p</c:mi></c:math> < 0.001). The use of mechanical valves rose in the current era ( <e:math xmlns:e="http://www.w3.org/1998/Math/MathML" id="M3"><e:mi>p</e:mi></e:math> < 0.001 compared to early TAVR). Regression analysis showed that the year of surgery was not predictive of mechanical valve use, suggesting that changes in practice were driven by patient characteristics. Conclusion. Surgical valve choice since the adoption of TAVR has changed, with less frequent use of smaller valves. Increases in mechanical valve usage are likely a reflection of changing patient population.