Objectives: The 2021 European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines for the management of valvular heart disease continues to recommend transcatheter aortic valve implantation (TAVI) for treatment of severe symptomatic aortic valve stenosis (AS) in patients ˃ 75 years. However, surgical aortic valve replacement (SAVR) is a valid option for elderly patients, especially in particular anatomical subsets or clinical circumstances. The aim of this study was to analyze indications for SAVR and postoperative outcomes in elderly patients ˃75 years considering the ESC guidelines for valvular heart disease.
Methods: Database was searched for patients > 75 years who underwent SAVR between 2017 and 2022 at our center. Patients with concomitant valve, aortic or bypass procedures were excluded as well as patients subject to trial data embargo policy. Subsequently, 43 patients with isolated AS aged > 75 years (51% male; STS / EuroSCORE II of 1.7±0.6% / 1.7±0.4%) remained for analysis. Acute procedural and early clinical outcomes were adjudicated in accordance with standardized VARC-3 definitions. 
Results: Age distribution was: 75-76 years in 32.5% (14/43), 77-79 years in 46.5% (20/43) and 80-83 years in 21% (9/43) of patients. Reasons for SAVR were: very low operative risk according to STS (1.6±0.3%) and EuroSCORE II (1.4±0.3%) in 48.8% (21/43), unicuspid or bicuspid aortic valve in 21% (9/43), patient wish in 13.9% (6/43), large aortic annulus in 4.6% (2/43) and massive calcification of the left ventricular outflow tract in 4.6% (2/43). Concomitant procedures included left atrial appendage occlusion and/or cryoablation for atrial fibrillation in 27.9% (12/43) of patients. SAVR was conducted via partial upper sternotomy in 24/43 (55.8%) and full-sternotomy in 19/43 (44.2%) of cases. Mean aortic cross clamp and cardiopulmonary bypass times were 67.1±18.2 min and 98.6±25.1 min, respectively. Implanted valves consisted of stented porcine bioprostheses in 51.2% (22/43), stented bovine bioprostheses in 25.5% (11/43) and sutureless biological valves in 23.3% (10/43). 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), respectively. Bleeding complications and permanent pacemaker implantation were observed in 9.3% (4/43) and 4.6% (2/43) respectively. Acute kidney injury and stroke occurred in 4.6% (2/43) and 0% (0/43). In one case, percutaneous coronary intervention due to postoperative increase in troponin and known stenosis of the left circumflex artery was performed. Intensive care unit and total hospital stay were 2.9±2.1 days and 12.5±3.6 days. Post-procedure echocardiography demonstrated absence of any paravalvular leakage (PVL) in all but one patient with ≥ moderate PVL.  Mean transvalvular pressure gradient was 11.4±4.5 mmHg.
Conclusions: In our experience, SAVR is infrequently performed in patients > 75 years. However, although included patients are highly selected, the herein presented excellent results show that SAVR is still a reasonable treatment for elderly patients with a 30d mortality of 0%.   Therefore, heart team evaluation of every patient with AS and subsequent individual treatment decisions are of paramount importance to achieve optimized outcomes.