Surgical aortic valve replacement in Australia, 2002–2015: temporal changes in clinical practice, patient profiles and outcomes

Abstract

Background This study describes the temporal changes in risk profiles and outcomes among patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) in Australia between 2002 and 2015. Methods Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, we identified first‐recorded SAVR for AS over 14 years. Patients’ surgical risk profiles, procedures, 30‐day and 12‐month outcomes were summarized before and after the introduction of transcatheter aortic valve implantation in Australia, in 2008. We applied multivariable regression models to investigate the changes over time on risk‐adjusted 30‐day mortality, re‐hospitalization and 12‐month mortality. Results We identify a total of 18 147 patients with AS who underwent SAVR; mostly men (64%) with a mean age of 72 years. The proportion of major cardiac surgeries devoted to SAVR increased from 14% in 2002 to 20% in 2015. More SAVRs were performed electively (80% in 2002 versus 86% in 2015), and the recipients were at lower surgical risk (mean multi‐risk score 3.9% in 2002 versus 3.0% in 2015). The use of bioprosthetic aortic valves increased over time (67% in 2002 to 88% in 2015). We found no significant changes in 30‐day mortality, a significant decrease in 30‐day readmission and minor fluctuations in 12‐month mortality over the study period. Conclusion SAVR comprises an increasingly larger proportion of all adult cardiac surgeries in Australia. There has been a greater use of bioprosthetic aortic valves, a fall in 30‐day readmission but no significant changes in mortality.

Uncovering the treatable burden of severe aortic stenosis in Australia: current and future projections within an ageing population

“…This may well be explained by the demographic profile of those undergoing SAVR in Australia. As reported [ 18 ], the mean age of SAVR cases is around 72 years of age and only 37 % were female. Alternatively, the mean age of those with severe AS (during a similar timeframe of surveillance) within the NEDA cohort is around 80 years of age and, consistent with this report, more than half of cases were women.…”

“…In the setting of specific surgical registry reports [ 18 ] and recent insightful data generated by the NEDA Study [ 3 ] but little else, we present a unique analysis of the potential treatable burden of severe AS in Australia. As with many substantive public health issues that routinely affect a large proportion of the population and is associated with costly treatment and historically poor health outcomes [ 13 , 14 ], unfortunately there is a paucity of specific burden of disease data to guide health resources and clinical practice.…”

“…A recent analysis of 18,147 patients (mean age 72 years and 64 % men) with AS who underwent SAVR captured by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database during 2002–2015, showed that this procedure accounted for 20 % of all adult cardiac surgeries by the end of the study period [ 18 ]. In recent years, TAVR has been successfully applied to patients with severe AS and with high/prohibitive surgical risk [ 5 – 7 ]; with two randomized trials reporting the non-inferiority [ 8 ] and superiority [ 9 ] of TAVR in respect to mortality and subsequent risk of stroke, respectively, when compared to SAVR in low-risk patients with severe AS.…”

“…However, there does appear to be a disconnect between the number of Australians with severe AS who might benefit either SAVR or TAVR and their subsequent access to these procedures. A recent report from the ANZSCTS database recorded ~ 4,000 SAVR procedures overall in Australia during the period 2009–2015 [ 18 ]. Even when accounting for the fact that registry did become truly national until 2015, there appears to be a large shortfall in the expected number of such procedures per annum relative to our projections.…”

Trends in Transcatheter Aortic Valve Implantation in Australia

“…Despite the recent acceleration in TAVI numbers, the uptake of TAVI in Australia has been relatively slow compared to that of the northern hemisphere, and SAVR continues to be the dominant form of aortic valve intervention, with only 6–10% of all aortic valve procedures being performed using a transcatheter approach between 2013 and 2015. [ 13 ] TAVI continues to be restricted by limited public funding that caps the number of procedures able to be offered at each centre per year. The penetration of TAVI in Australia has increased from 48 cases per million in 2016, to 81 cases per million in 2018, and 119 cases per million in 2019.…”