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Background Prior studies showed that life expectancy in patients who underwent surgical aortic valve replacement (AVR) was lower than in the general population. Explanations for this shorter life expectancy are unknown. The aim of this nationwide, observational cohort study was to investigate the cause‐specific death following surgical AVR. Methods and Results We included 33 018 patients who underwent primary surgical AVR in Sweden between 1997 and 2018, with or without coronary artery bypass grafting. The SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register and other national health‐data registers were used to obtain and characterize the study cohort and to identify causes of death, categorized as cardiovascular mortality, cancer mortality, or other causes of death. The relative risks for cause‐specific mortality in patients who underwent AVR compared with the general population are presented as standardized mortality ratios. During a mean follow‐up period of 7.3 years (maximum 22.0 years), 14 237 (43%) patients died. The cumulative incidence of death from cardiovascular, cancer‐related, or other causes was 23.5%, 8.3%, and 11.6%, respectively, at 10 years, and 42.8%, 12.8%, and 23.8%, respectively, at 20 years. Standardized mortality ratios for cardiovascular, cancer‐related, and other causes of death were 1.79 (95% CI, 1.75–1.83), 1.00 (95% CI, 0.97–1.04), and 1.08 (95% CI, 1.05–1.12), respectively. Conclusions We found that life expectancy following AVR was lower than in the general population. Lower survival after AVR was explained by an increased relative risk of cardiovascular death. Future studies should focus on the role of earlier surgery in patients with asymptomatic aortic stenosis and on optimizing treatment and follow‐up after AVR. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02276950.

Prosthetic valve endocarditis (PVE) is the most severe form of infective endocarditis and accounts for 20% of all cases of infective endocarditis.1,2 However, studies reporting the incidence of PVE after surgical aortic valve replacement (AVR) are scarce and based mainly on noncontemporary patient cohorts. Whether PVE affects biological and mechanical aortic valves to the same extent remains unknown. Therefore, we investigated the incidence and risk of PVE after surgical AVR in patients with biological and mechanical valves. This observational, nationwide, population-based cohort study was approved by the regional Human Research Ethics Committee in Stockholm, Sweden (Dnr. 2016/1241-32) and is registered at ClinicalTrials.gov (Unique identifier: NCT02276950). No informed consent from patients was required. The SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) register was used to obtain the study population. The unique personal identity number was used for cross-linking patient-level data from other national healthcare registers as described previously.3 All patients who underwent AVR with a biological or mechanical valve prosthesis in Sweden from January 1, 1995, to December 31, 2012, were included in the study. Patients with multiple valve surgeries were excluded. Person-time in days was counted from the date of surgery until the …

We thank Madias for his interest in our work1 and the interesting points he raised. According to Madias2 and based on experimental work in animals, it has been suggested that aspirin could prevent infective endocarditis. Hypothetically, platelets are involved when bacteria adhere to abnormal or damaged endothelium by acting together with fibrin, extracellular matrix proteins, and surface adhesions on bacteria. It is therefore possible that drugs targeting platelet function could reduce the risk of infective endocarditis. Madias correctly noted that our study was …