Trends in Aortic Valve Replacement for Elderly Patients in the United States, 1999-2011

Nov 17, 2013
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Authors:
Barreto-Filho JA, Wang Y, Dodson JA, et al.
Citation:
JAMA 2013;310:2078-2085.
Summary By:
Debabrata Mukherjee, MD, FACC

Study Questions:

What are the procedure rates and outcomes of surgical aortic valve replacement (AVR) over time?

Methods:

A serial cross-sectional cohort study of 82,755,924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011 was performed. Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates were the main outcome measures.

Results:

The AVR procedure rate increased by 19 (95% confidence interval [CI], 19-20) procedures per 100,000 person-years over the 12-year period (p < 0.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%-4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. AVR with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosthetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011.

Conclusions:

The authors concluded that between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially.

Perspective:

This study describes a national increase in the rates of AVR and a reduction in mortality, readmission, and length of stay for Medicare beneficiaries undergoing the procedure from 1999 through 2011. Rates of AVR without CABG surgery Increased, while rates of AVR with it decreased, but adjusted annual decreases in 30-day mortality were comparable for either procedure. Mechanical aortic valve prostheses continued to be used in about one-quarter of elderly patients in 2011. These findings may provide a useful benchmark for outcomes of AVR surgery for older patients eligible for surgery considering newer transcatheter valve treatments.

Keywords: Coronary Artery Bypass


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