Over 14 Years at One Major Cardiac Center, the Average Patient Undergoing Open Aortic Valve Replacement Got Six Years Younger. The Average Patient Undergoing Coronary Bypass Got Healthier, Not Sicker.

Anyone working in a cardiothoracic operating room over the past decade has likely sensed a shift in who actually ends up on the table. This single-center study from Tel Aviv Sourasky Medical Center puts numbers behind that intuition. As transcatheter technologies including TAVR and transcatheter mitral repair have matured, the patient population still being referred for open surgery has changed in ways that are not simply explained by an aging or increasingly comorbid general population. Having spent time in the operating room as an anesthesia technician on a number of these cases, I found this paper answered a question I had been asking myself while setting up for these surgeries: is the case mix I am seeing actually shifting, or does it just feel that way?

Sela and colleagues conducted a retrospective ecological analysis of every patient who underwent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR), or mitral valve repair or replacement (MVR), with or without tricuspid intervention, at their center from January 2010 through December 2023. A separate analysis was performed for patients undergoing combined multivalve procedures. Data on age, sex, and Charlson comorbidity index (CCI), a validated scoring system estimating mortality risk from accumulated comorbidities, were extracted from electronic health records using an automated data-exploration platform. Spearman's rank correlation was used to test for significant monotonic trends across the 14-year period for each procedure type.

A total of 3,287 patients underwent isolated CABG, 700 underwent isolated AVR, 497 underwent isolated MVR, and 224 underwent multivalve procedures over the study period. For CABG, mean patient age declined from 68.0 years in 2010 to 64.6 years in 2023, the proportion of male patients rose from 79.7% to 83.1%, and mean CCI score dropped from 3.16 to 2.51, all statistically significant trends. For isolated AVR, the shift was even more pronounced: mean age fell from 69.2 to 62.9 years, a six-and-a-half-year decline, and mean CCI dropped from 3.64 to 2.32. The AVR sex distribution trend did not reach statistical significance. For isolated MVR, none of the three measures, age, sex distribution, or CCI, showed a statistically significant trend across the study period. For multivalve procedures, only the CCI trend reached significance, declining from a mean of 3.00 in 2010 to 2.24 in 2023.

• —This is a single-center study from one tertiary hospital in Israel. Referral patterns, local heart team composition, and institutional adoption speed for transcatheter technologies vary substantially across health systems, and these exact trends may not generalize to other centers or countries.
• —The study captured only surgical patients. Without parallel data on the transcatheter population referred to PCI, TAVR, or TEER at the same institution over the same period, the analysis cannot directly quantify how many patients shifted from surgery to a transcatheter pathway, only that the surgical population itself changed.
• —Fourteen years of follow-up introduces potential calendar bias. Changes in surgical team composition, referring cardiologist preferences, and institutional practice patterns unrelated to the transcatheter narrative cannot be fully excluded as contributing factors.
• —Aortic valve pathology was not stratified by mechanism, stenosis versus regurgitation, and TAVR is largely inapplicable to pure aortic regurgitation. This limits interpretation of referral logic for that specific and clinically important subgroup.

Cardiothoracic surgery is not simply treating an older, sicker population over time. For the two procedures where transcatheter alternatives have matured, CABG and AVR, the surgical population has gotten younger and healthier as higher-risk patients are increasingly diverted to catheter-based care. For mitral disease, where transcatheter options remain less established, the surgical population has stayed the same. Whoever is on the table for open cardiac surgery today reflects two decades of accumulated evidence about who benefits most from which approach, not simply who happened to need an operation.