Transcatheter aortic valve replacement (TAVR) is now established as a safe and effective alternative to surgical aortic valve replacement (SAVR) across the surgical risk spectrum, with annualized volumes outpacing the use of SAVR in North America and Western Europe. Patients not previously considered candidates for SAVR have been eligible for consideration of TAVR, a less invasive and more easily tolerated method of valve replacement, for the past decade. Accordingly, it is of interest to determine whether rates of referral for AVR, inclusive of surgical and transcatheter approaches, have increased over a portion of this timeframe and whether correctable practice gaps remain.
Eugène et al present a subanalysis of the previously reported 2017 EORP VHD II survey conducted across 222 centers in 28 countries over 3 months of 2017. The current analysis focuses on the outcomes of 1,271 patients who were symptomatic with severe high gradient AS, of whom approximately 80% were referred for AVR. The investigators intended to compare these results with the findings from 2001 Euro Heart Survey, which used a similar instrument. For the 20% of patients who were not referred for AVR despite meeting a Class I indication, older age, milder symptoms, heart failure, and combined comorbidities were independently associated with the lack of referral for AVR at the time of index evaluation.
Intervention was performed within the 3-month enrollment period in 57% of patients for whom a decision to intervene was made. Among the remaining 43% of patients referred for AVR, intervention was scheduled at some later time, with more than one-half of these scheduled patients waiting 6 months or longer for AVR. It is important to note that the AVR outcomes reported include events that pertain to all patients who underwent intervention during the study period and not just those with isolated, symptomatic severe high gradient AS. At 6-month follow-up, survival was higher in the group referred for AVR than in the group in which a decision to not intervene was made. This survival difference remained significant after adjustment for baseline surgical and clinical risk.
Although TAVR is now established as an alternative to SAVR for the management of severe AS, it is clear that not all patients will predictably derive benefit. Whether the 20% rate of nonreferral in the current study represents an appropriate threshold cannot be determined. There is the additional need to improve patient awareness, community screening, access to care, resource allocation, and clinician education. Eugène et al have provided an updated snapshot of AVR referral that can serve as a valuable performance metric. Their findings imply that practice gaps are closing, though there is clear room for further improvement.