Surgical Aortic Valve Replacement in Patients Above the Guideline-endorsed Age Cut-off: Reasons for Surgery and Clinical Outcomes

Abstract

Objectives

The 2017 and 2021 ESC/EACTS guidelines for the management of valvular heart disease recommend transcatheter aortic valve implantation (TAVI) as a treatment option for severe symptomatic aortic valve stenosis (AS) in patients ≥75 years of age. However, surgical aortic valve replacement (SAVR) remains a viable option for elderly patients, particularly in specific anatomical or clinical subsets. The objective of this study was to analyze indications for SAVR and postoperative outcomes in patients ≥75 years of age.

Methods

Heart team protocols were reviewed to determine indications for SAVR. The adjudication of acute procedural and early clinical outcomes was conducted in accordance with the standardized VARC-3 definitions. Furthermore, cardiovascular mortality and rate of aortic valve re-intervention were assessed at latest follow-up with a median duration of 5.5 years (1.9–7.1 years).

Results

A total of 43 patients ≥75 years of age (51% male) underwent isolated SAVR at our center between 2017 and 2022. STS/EuroSCORE II was 1.7 ± 0.6%/1.7 ± 0.4%. The age distribution of patients was as follows: 75 to 76 years in 32.5% (14/43), 77 to 79 years in 46.5% (20/43), and 80 to 83 years in 21% (9/43) of patients. Indications for SAVR included low operative risk according to STS (1.6 ± 0.3%) and EuroSCORE II (1.4 ± 0.3%) in 51.2% (22/43), unicuspid/bicuspid aortic valve in 21% (9/43), patient preference in 13.9% (6/43), large aortic annulus in 9.3% (4/43), and massive calcification of the left ventricular outflow tract in 4.6% (2/43) of patients. Mean aortic cross clamp and cardiopulmonary bypass times were 67.1 ± 18.2 minutes and 98.6 ± 25.1 minutes. All-cause 30-day mortality was 0% (0/43). Technical success, device success, and early safety were 100% (43/43), 100% (43/43), and 81.4% (35/43). Bleeding complications and the need for permanent pacemaker implantation (PPM) were observed in 9.3% (4/43) and 4.6% (2/43) of patients. Mean ICU and hospital stay were 2.9 ± 2.1 days and 12.5 ± 3.6 days. Post-procedural echocardiography demonstrated absence of paravalvular leakage (PVL) in all but one patient, who exhibited moderate PVL. The mean transvalvular pressure gradient was 11.4 ± 4.5 mmHg. Latest follow-up was at median 5.5 years (1.9–7.1 years). Aortic valve re-intervention at follow-up was 2.3% (1/43) and cardiovascular mortality was 4.6% (2/43).

Conclusion

In the current era, SAVR is rarely performed in patients ≥75 years of age. Despite the highly selective nature of the patient cohort studied, the results are excellent, with a 30-day mortality of 0% and a low cardiovascular mortality at 5 years. SAVR should still be considered a valid option in elderly patients, evaluated by a heart team, which considers each patient's unique clinical, anatomic, and procedural characteristics.

Keywords

surgical aortic valve replacement - guidelines - transcatheter aortic valve implantation - aortic valve stenosis

Data Availability Statement

All relevant data are within the manuscript and its Supporting Information files.

^‡ These authors contributed equally to this aricle.

Publication History

Received: 15 February 2025

Accepted: 15 October 2025

Accepted Manuscript online:
18 October 2025

Article published online:
31 October 2025

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