{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T14:06:31Z","timestamp":1791209191358,"version":"4.1.0"},"reference-count":27,"publisher":"BMJ","issue":"2","license":[{"start":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T00:00:00Z","timestamp":1791158400000},"content-version":"unspecified","delay-in-days":96,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Open Heart"],"accepted":{"date-parts":[[2026,9,17]]},"published-print":{"date-parts":[[2026,7]]},"abstract":"<jats:p>The natural history of symptomatic severe aortic stenosis (AS) heralds a poor prognosis\u2014a paradigm that rightly drives valve intervention. A widely voiced corollary holds that once patients exceed their nation\u2019s average life expectancy, aortic valve replacement offers no prognostic benefit. We argue that this corollary is statistically incoherent and potentially clinically harmful. Life expectancy at birth is a period average across a whole cohort, weighted by deaths at younger ages; it is not a ceiling on individual survival. Expectancy is conditional on survival already achieved: the longer a person has lived, the older they are expected to be at death. A man of 90 in England and Wales still has a mean of 3.9 years ahead of him, and an average 82-year-old will outlive an average 72-year-old. The patient who has 'beaten the average\u2019 has, by surviving, demonstrated membership of a longer-lived stratum\u2014precisely the group with most to gain from a durable valve. The hazard in AS is cardiac, not chronological: it tracks extravalvular cardiac damage, frailty and competing illness rather than the calendar, and stage, not age, discriminates outcome after valve replacement. Futility is real\u2014advanced cardiac damage, established frailty and prognosis-dominating comorbidity do foreclose benefit\u2014but age is an inaccurate proxy for it. Drawing on natural history and clinical trial data, including cardiac damage staging, national life tables and the deprivation gradient, we propose replacing age-based nihilism with conditional, comorbidity-adjusted prognostication, with the expected gain estimated, documented and stated explicitly as part of consent and shared decision-making.<\/jats:p>","DOI":"10.1136\/openhrt-2026-004523","type":"journal-article","created":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T13:30:28Z","timestamp":1791207028000},"page":"e004523","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Life-expectancy paradox and the selection of older patients with aortic stenosis for valve intervention"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8909-5277","authenticated-orcid":false,"given":"Ozan M","family":"Demir","sequence":"first","affiliation":[{"name":"Essex Cardiothoracic Centre, Basildon, UK"},{"name":"Anglia Ruskin University, Chelmsford, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Azeem","family":"Latib","sequence":"additional","affiliation":[{"name":"Interventional Cardiology, Montefiore Einstein Center for Heart and Vascular Care, New York, New York, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bernard","family":"Prendergast","sequence":"additional","affiliation":[{"name":"Cardiology Department, Cleveland Clinic London, London, UK"},{"name":"Cardiology Department, St Thomas\u2019 Hospital, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,10,5]]},"reference":[{"key":"2026100506302349000_13.2.e004523.1","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.38.1S5.V-61"},{"key":"2026100506302349000_13.2.e004523.2","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2019.08.004"},{"key":"2026100506302349000_13.2.e004523.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2013.05.015"},{"key":"2026100506302349000_13.2.e004523.4","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehw229"},{"key":"2026100506302349000_13.2.e004523.5","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehi471"},{"key":"2026100506302349000_13.2.e004523.6","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.121.025065","article-title":"Patient\u2010 and Process\u2010Related Contributors to the Underuse of Aortic Valve Replacement and Subsequent Mortality in Ambulatory Patients With Severe Aortic Stenosis","volume":"11","author":"Flannery","year":"2022","journal-title":"JAHA"},{"key":"2026100506302349000_13.2.e004523.7","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.125.074470"},{"key":"2026100506302349000_13.2.e004523.8","doi-asserted-by":"crossref","first-page":"2485","DOI":"10.1016\/S0140-6736(15)60290-2","article-title":"5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial","volume":"385","author":"Kapadia","year":"2015","journal-title":"The Lancet"},{"key":"2026100506302349000_13.2.e004523.9","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2307447"},{"key":"2026100506302349000_13.2.e004523.10","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa2405880"},{"key":"2026100506302349000_13.2.e004523.11","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.121.057639"},{"key":"2026100506302349000_13.2.e004523.12","doi-asserted-by":"publisher","DOI":"10.1093\/eurheartj\/ehx381"},{"key":"2026100506302349000_13.2.e004523.13","doi-asserted-by":"crossref","first-page":"743","DOI":"10.1016\/j.jacc.2022.11.059","article-title":"Cardiac Damage and Quality of Life After Aortic Valve Replacement in the PARTNER Trials","volume":"81","author":"G\u00e9n\u00e9reux","year":"2023","journal-title":"J Am Coll Cardiol"},{"key":"2026100506302349000_13.2.e004523.14","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1161\/CIRCULATIONAHA.117.033432","article-title":"Temporal Trends and Clinical Consequences of Wait Times for Transcatheter Aortic Valve Replacement: A Population-Based Study","volume":"138","author":"Elbaz-Greener","year":"2018","journal-title":"Circulation"},{"key":"2026100506302349000_13.2.e004523.15","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2014.02.581"},{"key":"2026100506302349000_13.2.e004523.16","unstructured":"Office for National Statistics . 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Available: https:\/\/www.who.int\/data\/gho [Accessed 10 Sep 2026]."},{"key":"2026100506302349000_13.2.e004523.21","doi-asserted-by":"crossref","first-page":"4635","DOI":"10.1093\/eurheartj\/ehaf194","article-title":"2025 ESC\/EACTS Guidelines for the management of valvular heart disease","volume":"46","author":"Praz","year":"2025","journal-title":"Eur Heart J"},{"key":"2026100506302349000_13.2.e004523.22","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000000923"},{"key":"2026100506302349000_13.2.e004523.23","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.113.007477"},{"key":"2026100506302349000_13.2.e004523.24","doi-asserted-by":"crossref","DOI":"10.1161\/JAHA.115.002096","article-title":"Causes of Death Following Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis","volume":"4","author":"Xiong","year":"2015","journal-title":"J Am Heart Assoc"},{"key":"2026100506302349000_13.2.e004523.25","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2017.06.024"},{"key":"2026100506302349000_13.2.e004523.26","doi-asserted-by":"publisher","DOI":"10.1016\/j.jacc.2016.01.055"},{"key":"2026100506302349000_13.2.e004523.27","doi-asserted-by":"publisher","DOI":"10.1001\/jama.295.7.801"}],"container-title":["Open Heart"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/openhrt-2026-004523","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,5]],"date-time":"2026-10-05T13:30:30Z","timestamp":1791207030000},"score":1,"resource":{"primary":{"URL":"https:\/\/openheart.bmj.com\/lookup\/doi\/10.1136\/openhrt-2026-004523"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7]]},"references-count":27,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,10,5]]},"published-print":{"date-parts":[[2026,7]]}},"alternative-id":["10.1136\/openhrt-2026-004523"],"URL":"https:\/\/doi.org\/10.1136\/openhrt-2026-004523","relation":{},"ISSN":["2053-3624"],"issn-type":[{"value":"2053-3624","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7]]}}}