Contemporary review of severe aortic stenosis

Abstract

Severe aortic stenosis (AS) is the most common form of valvular heart disease in the developed world with a rising prevalence due to an ageing Australian population. Transcatheter aortic valve implantation (TAVI) offers a less invasive option for the treatment of severe AS with evidence supporting of TAVI compared to medical therapy in inoperable patients, and superior to surgical aortic valve replacement (SAVR) in high-risk patients. Equal outcomes have been observed in all-comer intermediate risk populations. The Heart Team utilises a shared decision-making approach between physicians and surgeons in risk stratifying patients and reduces the intrinsic bias that may occur if decisions are made in isolation. Geriatric assessment is useful in identifying pre-operative frailty, a major risk factor for death post aortic valve intervention. In severe AS, a decision can be made collaboratively to pursue TAVI, SAVR, a Ross Procedure, or conservative management. The learning curve associated with TAVI has improved markedly with overall complication rates decreasing around the world. Contemporary changes in practice such as conscious sedation without general anaesthesia, expedited recovery and early discharge will likely improve cost-effectiveness. In 2018, TAVI is a well-established procedure in Australia that has revolutionised the management of severe AS. In the future with an expanding elderly population, the number of patients to benefit from transcatheter therapies for severe AS is hypothesised to increase 4-10 fold. Heart Team assessment is crucial in patients with severe AS to direct appropriate management. This article is protected by copyright. All rights reserved.

Transcatheter aortic valve implantation for severe aortic stenosis in the Australian regional population

“…16 Dedicated and focused regional systems of care in aortic valve intervention have demonstrated improvements in outcomes and shorter length of stay. 11 It also highlights the framework required to run a successful TAVI program and service regional areas of need. Our study highlights the importance that regional Australian patients are not denied aortic valve intervention on the basis of geographical restriction.…”

“…Our study highlights the importance that regional Australian patients are not denied aortic valve intervention on the basis of geographical restriction. 11 It also highlights the framework required to run a successful TAVI program and service regional areas of need.…”

“…[8][9][10] TAVI involves delivery of a bioprosthetic aortic valve into the aortic annulus, via a retrograde approach from the aorta (Figure 1). 11 TAVI is non-inferior to SAVR in individuals with intermediate-risk severe AS. Patients do not require cardiopulmonary bypass or a sternotomy and can be discharged as early as day one post-procedure.…”

“…Patients do not require cardiopulmonary bypass or a sternotomy and can be discharged as early as day one post-procedure. 11 In 2017, the use of TAVI was approved by the Australian Government for the treatment of severe AS, with the number of procedures expected to rise up to 10 times in the future. 11 TAVI is non-inferior to SAVR in individuals with intermediate-risk severe AS.…”

“…11 In 2017, the use of TAVI was approved by the Australian Government for the treatment of severe AS, with the number of procedures expected to rise up to 10 times in the future. 11 TAVI is non-inferior to SAVR in individuals with intermediate-risk severe AS. 12 Risk factors and predictors of mortality have been well established in the literature; however, there are no Australian data that identify if a disparity exists between regional and remote patients, compared with urban patients in the treatment of severe AS.…”