The changing landscape of aortic valve replacement in the USA

Aims: The aim of this study was to analyse the real-world national data on parallel utilisation of transcatheter (TAVR) and surgical (SAVR) aortic valve replacement. Methods and results: We queried an all-payer, administrative United States in-patient database to identify all AVR hospitalisations in patients aged ≥18 years from January 2012 to December 2016 and examined the temporal changes in the number of AVR procedures and in-hospital mortality. A total of 463,675 AVRs were performed - 363,275 (78.4%) SAVR and 100,400 (21.6%) TAVR. AVR linearly increased (from 78,985 in 2012 to 103,415 in 2016; +30.9%; p_trend<0.001) largely due to a marked increase in TAVR (from 7,655 to 33,545; +338%; p_trend<0.001), whereas the absolute number of SAVRs remained relatively stable (from 71,330 to 69,870; -1%; p_trend<0.001). The number of TAVRs increased in all pre-specified age groups (<75, 75-79, 80-85, and ≥85 years; p_trend<0.001 for all). In contrast, the number of SAVRs increased modestly in patients aged <75 years (p_trend<0.001) and declined in those aged 75-79 years, 80-84 years, or ≥85 years (p_trend<0.001 for all). Age- and sex-adjusted in-hospital mortality after isolated (aOR 1.00 [0.95-1.05]; p_trend=0.96) or combined SAVR (aOR 1.01 [0.97-1.05]; p_trend=0.66) remained unchanged during the study period, whereas in-hospital mortality after TAVR declined (aOR 0.75 [0.70-0.79]; p_trend<0.001). Similar trends in in-hospital mortality were seen in the age subgroups. Conclusions: The number of AVRs markedly increased in the USA from 2012 to 2016, mainly due to the widespread adoption of TAVR, whereas the number of SAVRs remained relatively stable. In-hospital mortality after TAVR declined, whereas that after SAVR has remained unchanged.