European and US clinical practice guidelines for choice of aortic valve intervention in adults with aortic stenosis (AS) were updated in 2020 and 2021 including recommendations on patient selection when deciding between transcatheter aortic valve implantation (TAVI) and a surgical bioprosthetic or mechanical valve.1 In order to determine if clinical practice patterns match guideline recommendations, Graversen and colleagues used data from three national registries to identify 16 043 patients undergoing first-time aortic valve replacement (AVR) for aortic stenosis between 2008 and 2020.2 Over this time period, the rate of AVR per million inhabitants increased by 39% and there was a decline in the number of surgical AVRs with a reciprocal increase in TAVI volumes, such that TAVI accounted for 64.2% of all AVRs and 72.5% of isolated AVRs by 2020. In patients aged 75 years or older with AS, TAVI accounted for 91.5% of all AVR procedures, which reflects close alignment with current guidelines (figure 1). The data on younger patients are more difficult to interpret, with an increased use of TAVI and lower rates of surgical AVR, despite guidelines suggesting surgical AVR is more appropriate in this age group. It is reassuring that for the 2016–2020 cohort, the mean age of patients undergoing TAVI was 81.4 years compared with 72.2 years for those receiving a bioprosthetic surgical AVR and 56.3 years for those receiving a mechanical AVR at surgery.

Annual proportion of isolated AVRs according to age. The proportion of isolated AVRs performed between 2008 and 2020 according to the type of AVR in two age categories (<75 and …