Trends in Utilization of Aortic Valve Replacement for Severe Aortic Stenosis

Li, Shawn X.; Patel, Nilay; Flannery, Laura; Selberg, Alexandra; Kandanelly, Ritvik R.; Morrison, Fritha; Kim, Joonghee; Tanguturi, Varsha K.; Crousillat, Daniela R.; Shaqdan, Ayman; Inglessis, Ignacio; Shah, Pinak; Passeri, Jonathan J.; Kaneko, Tsuyoshi; Jassar, Arminder S.; Langer, Nathaniel B.; Turchin, Alexander; Elmariah, Sammy

doi:10.1016/j.jacc.2021.11.060

Cited by 26 publications

(14 citation statements)

References 24 publications

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“…26 Even in the most well resourced health systems, aortic valve replacement rates remain lower than expected. 27 The inexorable ageing of many high-income populations will inevitably impart an increasingly challenging and unsustainable societal burden and health-care expenditure if there is no development and application of pragmatic preventive strategies for key contributors of future costs such as aortic stenosis.…”

Section: Discussionmentioning

confidence: 99%

Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study

Stewart

Afoakwah

Chan

et al. 2022

The Lancet Healthy Longevity

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Section: Discussionmentioning

confidence: 99%

Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study

Stewart

Afoakwah

Chan

et al. 2022

The Lancet Healthy Longevity

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“…The low rate of intervention in this study could be explained by the fact that TAVR was not fully employed during the early years of the study. However, contemporary reports show continued under-utilization of this resource, even in academic centers [ 28 ]. The prediction model presented in this study is based on claims data in the form of ICD10 codes, which limited our ability to include important factors in the model.…”

Section: Discussionmentioning

confidence: 99%

One and Five-Year Mortality Risk Prediction in Patients with Moderate and Severe Aortic Stenosis

Yousef

Amabile

Huang

et al. 2022

JCM

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(1) Background: Our goal was to develop a risk prediction model for mortality in patients with moderate and severe aortic stenosis (AS). (2) Methods: All patients aged 40–95 years, with echocardiographic evidence of moderate and severe AS at a single institution, were studied over a median of 2.8 (1.5–4.8) years, between 2013–2018. Patient characteristics and mortality were compared using Chi-squares, t-tests, and Kaplan–Meier (KM) curves, as appropriate. The risk calculation for mortality was derived using the Cox proportional hazards model. A risk score was calculated for each parameter, and the total sum of scores predicted the individualized risks of 1-and 5-year mortality. (3) Results: A total of 1991 patients with severe and 2212 with moderate AS were included. Severe AS patients were older, had a lower ejection fraction %, were more likely to be Caucasian, and had lower rates of obesity and smoking, but had higher rates of cardiac comorbidities and AVR (49.3% vs. 2.8%, p < 0.0001). The unadjusted overall mortality was 41.7% vs. 41%, p = 0.6530, and was not different using KM curves (log rank, p = 0.0853). The models included only patients with complete follow-up (3966 in the 1-year, and 816 in the 5-year model) and included 13 variables related to patient characteristics, degree of AS, and AVR. The C-statistic was 0.75 and 0.72 for the 1-year and the 5-year models, respectively. (4) Conclusions: Patients with moderate and severe AS experience high morbidity and mortality. The usage of a risk prediction model may provide guidance for clinical decision making in complex patients.

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“…These results support the growing body of recent work which illustrates the positive utility of AVR in low-EF patients with AS [13] or AR [14,15], but with a specific focus on SAVR. It is perhaps surprising that in recent years, the valve intervention rate has not been increasing as quickly as might be expected given the mounting evidence of the efficacy and safety of these valve procedures [4].…”

Section: Discussionmentioning

confidence: 99%

“…Despite subsequent advancements in the medical and surgical landscape, AVR is still likely underutilized. A recent report from 2022, for example, showed that in over 6000 AS patients for whom it was indicated or potentially indicated, only 48% of patients had an AVR [4]. Importantly, a low EF (<50%) was found to be a significant predictor of patients not receiving an AVR.…”

Section: Introductionmentioning

confidence: 99%

“…The absolute number of low EF patients receiving an AVR has generally increased over the past several years, though this is largely owing to an increase in AS prevalence, which tracks with the aging population; the proportion of symptomatic cases receiving an AVR has reportedly remained steady since 2001. The rise in interventions is driven by TAVR, while the use of SAVR has generally declined in relative and absolute terms [4]. TAVR already makes up the majority of AVRs, including in over 80% of severe AS cases in Germany that were treated procedurally [5].…”

Section: Introductionmentioning

confidence: 99%

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Aortic Valve Replacement in the Failing Left Ventricle: Worthwhile?

Kalyanasundaram¹,

Vinholo²,

Zafar³

et al. 2022

Rev. Cardiovasc. Med.

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According to the 2020 American College of Cardiology/American Heart Association guidelines, the aortic valve should be replaced in the setting of severe aortic stenosis or regurgitation, independent of left ventricular function (even for EF <55%). However, in clinical practice, especially in a very low EF range, surgeons may avoid surgical aortic valve replacement (SAVR) because of concern over operative risk. This study examines outcomes of patients with EF ≤35% undergoing SAVR. Methods: From 2004 to 2019, 895 patients underwent SAVR for aortic stenosis (AS) and/or regurgitation (AR) by a single surgeon at our institution. From among these, 40 patients (4.47%) had an ejection fraction (EF) of 35% or less, forming the study group. Intra-aortic balloon pump was placed intraoperatively prophylactically pre-bypass in 18 out of the 40. Preoperative and post-operative echocardiograms were compared to determine changes in ejection fraction. Mid-term survival was assessed. Results: 16 patients presented with AS, 20 with AR, and 4 with a combination of AS and AR. Hospital survival was 97.5% (one patient death). The average ejection fraction progressively improved over time from 26% initially to 46% mid-term with mean follow-up of 43 months (0.1-140.7). Remarkably, five-year survival was comparable between the study group and an age-and gender-matched general population (p = 0.834). Downward trends in LV end-diastolic diameter and end-systolic diameter were seen. The former achieved statistical significance (6.0 cm to 5.3 cm; p = 0.0046), while the latter fell slightly short (4.8 cm to 4.1 cm; p = 0.056). Patients in whom an IABP was used had lower EFs than those without IABP (range 10-35, mean 23% vs. 15-35%, mean 27.6%). The EFs of the three subgroups improved significantly postoperatively (p < 0.001 for AS, p = 0.002 for AR, and p = 0.046 for AS and AR). Conclusions: Surgical AVR can be done safely in patients with a failing LV with EF ≤35%. Significant improvements in the ejection fraction are seen over time. We believe there is a role for prophylactic pre-bypass IABP. Five-year survival is normalized. Surgeons should not hesitate to perform AVR in these highly jeopardized patients.

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Trends in Utilization of Aortic Valve Replacement for Severe Aortic Stenosis

Cited by 26 publications

References 24 publications

Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study

Counting the cost of premature mortality with progressively worse aortic stenosis in Australia: a clinical cohort study

One and Five-Year Mortality Risk Prediction in Patients with Moderate and Severe Aortic Stenosis

Aortic Valve Replacement in the Failing Left Ventricle: Worthwhile?

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