Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice

Abstract

ObjectiveApproximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR.MethodsParticipants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR.ResultsOf 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR.ConclusionsThere may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.

Patterns of Aortic Valve Replacement in Europe: Adoption by Age

“…In the overall analysis, the use of TAVI increased in all age groups between 2015 and 2019, including in patients aged <65 years. This might suggest that in some European countries, real-world clinical practice differs from the latest guideline recommendations, something which has been noted previously in Europe and the USA [50, 51]. However, there are various possible reasons for using TAVI in younger age groups, such as patients being high risk, patient preference, and an increasing level of surgical experience and availability of improved devices leading to younger high-risk patients being treated.…”

Early surgical intervention versus conservative management of asymptomatic severe aortic stenosis: a systematic review and meta-analysis

“…Until comparable long-term durability is established, SAVR remains the first choice for lower-younger patients. Real-world data show that percutaneous techniques in the treatment of AS, an increasing number of patients are undergoing TAVR while asymptomatic 27…”

Timing of Intervention in Asymptomatic Patients with Aortic Stenosis

“…However, real-world data show that with the emergence of percutaneous techniques in the treatment of AS, an increasing number of patients are undergoing TAVR while asymptomatic. 67 A recent prospective multinational registry of patients with severe AS across Europe reported that, in the subgroup of 392 asymptomatic patients who were clinically evaluated to decide on treatment, AVR was decided on for 153 patients and, in 58% of cases, was performed percutaneously. 67 In that registry, up to 66 patients underwent TAVR while asymptomatic and having no formal indication according to current clinical guidelines.…”

“…67 A recent prospective multinational registry of patients with severe AS across Europe reported that, in the subgroup of 392 asymptomatic patients who were clinically evaluated to decide on treatment, AVR was decided on for 153 patients and, in 58% of cases, was performed percutaneously. 67 In that registry, up to 66 patients underwent TAVR while asymptomatic and having no formal indication according to current clinical guidelines. As the technique improves and the complications of the procedure decrease, the indications for TAVR are expanding.…”