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ortic valve disease in the United States is a major cardiovascular problem that is likely to grow as the population ages. [1][2][3][4][5] Aortic valve replacement is the standard treatment even for very elderly patients despite its risks in this age group. 6 With transcatheter aortic valve replacement emerging as a less invasive option, 7-9 contemporary data from real-world practice are needed to provide a perspective on the outcomes that are being achieved with surgery.Changes in practice during the past decade are partly due to growing recognition that the benefits of aortic valve replacement extend to extremes in patient age. 10,11 There is also a recommendation for consideration of earlier, preemptive aortic valve replacement in selected asymptomatic patients 12 and strong guidance that bioprostheses rather than mechanical valves be used for patients 65 years or older. 13,14 There is also uncertainty about the benefit of performing coronary artery bypass graft (CABG) surgery during aortic valve replacement in patients with stable coronary disease. 8,15,16 Previous studies have indicated that rates of aortic valve replacement are increasing and outcomes are improving [17][18][19][20] but do not provide population-based rates and long-term follow-up. [17][18][19][20] We therefore studied aortic valve replacement among Medicare fee-for-service beneficiaries between 1999 and 2011. We calculated trends in rates of surgical aortic valve replacement and outcomes defined as mortality, readmission, and length of stay. In addition, we compared the outcomes of pa-IMPORTANCE There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge.OBJECTIVE To assess procedure rates and outcomes of surgical AVR over time. DESIGN, SETTING, AND PARTICIPANTSA serial cross-sectional cohort study of 82 755 924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011. MAIN OUTCOMES AND MEASURESProcedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates. RESULTSThe AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100 000 person-years over the 12-year period (P<.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%-4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. Aortic valve replacement with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosethetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011. CONCLUSIONS AND RELEVANCEBetween 1999 and 2011, the rate of ...