Interventional cardiology

Rise of TAVI at the expense of mechanical valves for younger patients

The shift to less invasive transcatheter aortic valve implantation (TAVI) raises the question of the role of mechanical valves for younger patients, according to a paper by Australian cardiologists.

An analysis of Australian Institute of Health and Welfare data, published in the Internal Medicine Journal, found the proportion of mechanical aortic valve replacements (AVRs) implanted fell from 38.4% to 8.6% between 2004 and 2019.

The study also found TAVI rates jumped 52% each year from 2014, amid its listing on the Medical Benefits Schedule in late 2017 and would likely become “the dominant replacement option in Australia over the next few years as technology improves and indications widen”.

The change in treatments for severe stenosis came despite international recommendations continuing to advise mechanical AVRs for younger patients, said lead author Dr Paul Bamford, of the Cardiology Department, John Hunter Hospital, Newcastle, NSW.

“What’s interesting from our study is that whilst mechanical AVR are recommended for the younger cohorts, a larger proportion are now being treated with TAVI or bioprosthetic AVR,” he told the limbic.

“Whilst mechanical valves are certainly more durable, they require a lifetime of warfarin use, with its associated pitfalls. Against this, most bioprosthetic valves will require replacement after 10-15 years. When this occurs, patients will either require re-do surgery, which carries a high post-operative risk or they might be able to undergo valve-in-valve TAVI, which due to its novelty hasn’t got much long-term data as yet.”

Dr Bamford said the shift to TAVI over surgical valves might reflect patient choice, and there was also research indicating TAVI as a “non-inferior option” for low to moderate risk patients.

Despite the fall in surgical procedures, the study revealed an age-adjusted increase in all AVR, from 3631 to 7277 per year in absolute terms. They were also performed on increasingly older cohorts, particularly for men.

Dr Bamford said the European (ESC) and American (AHA) guidelines continued to recommend SAVR for younger patients. The ESC recommends SAVR for low-risk under 75-year-olds and TAVI for 75 years and older, as well as all with at least intermediate surgical risk. The AHA recommends SAVR for under 65s and TAVI for people in their 80s.

He pointed to an imminent change in Medicare Benefit for intermediate-risk TAVI with low-risk expected to follow.

“The paradigm appears to be shifting away from procedure choice based on surgical risk and towards other factors such as anatomical suitability and patient preference,” he said.

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