Background

The choice of intervention for aortic valve disease, transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR), has evolved significantly in recent years. Patients’ age, among other factors, has been proposed as a major criterion in decision making. We aimed to investigate current treatment indications and temporal trends according to age strata in patients with severe aortic valve disease in Germany.

Methods

In this retrospective study, healthcare records were obtained from the German Federal Bureau of Statistics. Between 2011 and 2020, all patients ≥40 years of age who received aortic valve procedures (SAVR or TAVI) in Germany were included. Diagnoses, comorbidities, and procedural aspects were assessed by ICD-10 and OPS codes and stratified according to age groups (<65 years, 65-69 years, 70-74 years, ≥75 years).

Results

Overall, 336,879 aortic valve procedures were performed in patients ≥40 years of age from 2011 to 2020 in Germany. The indication was aortic stenosis (87.9%), pure regurgitation (8.3%), bicuspid aortic valve disease (BAV, 2.1%) or endocarditis (3.0%). Treatment was SAVR in 54.8% or TAVI in 45.2% (2020: 36.5% SAVR vs. 63.5% TAVI). Isolated SAVR accounted for 48.8% of operations; the remainder included concomitant procedures (e.g., CABG in 38.2%). 40.2% of all procedures were performed in patients <75 years (<65 years: 15.2%; 65-69 years: 9.5%; 70-74: 15.6%). TAVI was the treatment of choice in 5.0% of patients <65 years, [2020: 9.3%], 14% of patients 65-69 years [2020: 22.7%], 22% of patients 70-74 years [2020: 41.7%]. In patients ≥75 years, TAVI was performed in 66.0% [2020: 85.7%]. In cases of pure regurgitation (n=30,399) TAVI occurred in 10.8% (<65 years: 2.1% [2020: 3.1%]; 65-69 years: 4.0% [2020: 6.3%]; 70-74 years: 7.1% [2020: 11.2%], ≥75 years 25.8% [2020: 33.0%]). BAV (n=7,674) was treated with TAVI in 3.6% of cases (<65 years: 0.7% [2020: 1.6%]; 65-69 years: 2.3% [2020: 5.3%]; 70-74 years: 4.4% [2020: 7.6%], ≥75 years 19.1% [2020: 46.23%]). TAVI for the treatment of endocarditis remained unchanged at 1.8% of cases overall.

Conclusion

In this German nationwide cohort, TAVI was frequently performed for the treatment of isolated aortic valve disease and a significant increase of TAVI was observed across all age groups in recent years. While aortic stenosis remained the main indication for treatment, the indication to perform TAVI was increasingly expanded to patients with bicuspid aortic valve disease and pure regurgitation, particularly in older patients.