Is Cardiology Overtreating Aortic Stenosis? with Linda Gillam, MD, MPH

The result of decades of progressive advancements and breakthroughs, use of TAVR as an alternative to surgical aortic valve replacement (SAVR) has exploded since initial approval in 2011 for patients with severe aortic stenosis with prohibitive risk.¹

In the 2020 guidelines on management of aortic stenosis from the American College of Cardiology and the American Heart Association, TAVR is considered appropriate in patients 65 years and older but recommends SAVR for low-risk patients younger than 65 years as valves in surgery are more durable over time. However, amidst the enthusiasm surrounding this new approach, recent data suggests there could be a growing discordance between use of TAVR and the guideline recommendations.^1,2,3

In 1 study from the American Association for Thoracic Surgery 2024 annual conference, investigators from Cedars Sinai Smidt Heart Institute found more than 50% of patients less than 65 years of age with severe aortic stenosis were undergoing TAVR in 2021, which was up from just 7% in 2013. This study, which leveraged data from more than 9800 patients from all-payer mandatory discharge datasets for California, New Jersey, and New York states, also found superior midterm survival outcomes with SAVR among these patients.²

An earlier study from the Society of Thoracic Surgeons’ 2024 Annual Meeting, which included data from more than 2300 patients less than 60 years of age, found by 2021 nearly 50% of patients were receiving TAVR rather than SAVR. This study also found use of SAVR was associated with a significantly greater rate of 5-year survival relative to TAVR.³

A leading subject matter expert, Linda Gillam, MD, MPH, chair of Cardiovascular Medicine at Morristown Medical Center, medical director of the Cardiovascular Service Line for Atlantic Health System and professor of Medicine at Thomas Jefferson University, spent time during September 2024 on the front lines of updates in this space, serving as a chairperson during a Hot Line session at the European Society of Cardiology 2024 Congress and presenting the role of imaging and biomarkers at Baptist Health’s Echocardiography and Structural Heart Symposium. As part of a recent interview highlighting both of these meetings, we asked Gillam for her opinion on whether there was a potential overtreatment of aortic stenosis.

Relevant disclosures for Gillam include Medtronic, Edwards Lifesciences, Boehringer Ingelheim, and Novartis.

References:

1. Mahmaljy H, Tawney A, Young M. Transcatheter aortic valve replacement. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; January 2024. Updated July 24, 2023.
2. Bowdish M. Transcatheter versus Surgical Aortic Valve Replacement in US Patients Younger than 65 Years of Age. Presented at The American Association for Thoracic Surgery. Toronto, ON. April 27-30, 2024.
3. The Society of Thoracic Surgeons. Almost 50% of patients under 60 years choose TAVR over SAVR with worse outcomes. STS. January 28, 2024. Accessed October 11, 2024. https://www.sts.org/press-releases/almost-50-patients-under-60-years-choose-tavr-over-savr-worse-outcomes.