Surgical valve selection in the era of transcatheter aortic valve replacement in the Society of Thoracic Surgeons Database

Objectives: Time trends in surgical valve selection have not been explored in detail in the era of transcatheter aortic valve replacement (TAVR) in nationally representative data. Herein, we explore valve selection trends in the TAVR era using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Methods: Isolated first-time biological or mechanical aortic valve replacements (AVR) from 2004 to 2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database were included. Patient characteristics were examined in the pre-TAVR era (2004-2007) and the post-TAVR era (2008-2016) using the year 2007 as the cut-point. Using a piece-wise regression analysis to model the relationship between time and type of valve used, a change-point analysis was performed to empirically determine the time of change in practice, both overall and in age-specific subgroups (<= 60 years and >60 years). Results: In total, 214,390 patients underwent isolated primary mechanical or biological AVR from 2004 to 2016. The patients' mean age increased slightly between the 2 eras (67.1 vs 68.6 years, P<.001), whereas the proportion of mechanical AVRs decreased (24.8% vs 12.2%, P<.001). Piece-wise regression demonstrated that the proportion of mechanical valves decreased over time. An empirically estimated slope change-point was found after the first quarter 2010; from 2004 to 2009, the overall proportion of mechanical valves was decreasing quickly (-2.81%/year, 95% confidence interval [95% CI], -3.03% to -2.60%), compared with 2010 to 2016. The early decline was steeper for younger patients (-4.21%/year, 95% CI, -4.74 to -3.69) compared with older patients (-1.44%/year, 95% CI -1.64 to -1.23). Conclusions: Use of mechanical AVR declined significantly from 2004 to 2016 and was decreasing before the introduction or the approval of TAVR in the United States.