The Evolving Management of Aortic Valve Disease: 5-Year Trends in SAVR, TAVR, and Medical Therapy

Abstract

Aortic stenosis (AS) and regurgitation (AR) may be treated with surgical aortic valve replacement (SAVR), transcatheter AVR (TAVR), or medical therapy (MT). Data are lacking regarding the usage of SAVR, TAVR, and MT for patients hospitalized with aortic valve disease and the characteristics of the patients and hospitals associated with each therapy. From the Nationwide Readmissions Database, we determined utilization trends for SAVR, TAVR, and MT in patients with aortic valve disease admitted from 2012 to 2016 for valve replacement, heart failure, unstable angina, non-ST-elevation myocardial infarction, or syncope. We also performed multinomial logistic regressions to investigate associations between patient and hospital characteristics and treatment. Among 366,909 patients hospitalized for aortic valve disease, there was a 48.1% annual increase from 2012 through 2016. Overall, 19.9%, 6.7%, and 73.4% of patients received SAVR, TAVR, and MT, respectively. SAVR decreased from 21.9% in 2012 to 18.5% in 2016, whereas TAVR increased from 2.6% to 12.5%, and MT decreased from 75.5% to 69.0%. Older age, female sex, greater severity of illness, more admission diagnoses, not-for-profit hospitals, large hospitals, and urban teaching hospitals were associated with greater use of TAVR. In multivariable analysis, likelihood of TAVR relative to SAVR increased 4.57-fold (95% confidence interval 4.21 to 4.97). TAVR has increased at the expense of both SAVR and MT, a novel finding. However, this increase in TAVR was distributed inequitably, with certain patients more likely to receive TAVR certain hospitals more likely to provide TAVR. With the expected expansion of indications, inequitable access to TAVR must be addressed.

Figure 1.

Trends in surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR), and medical therapy (MT) from 2012 to 2016: total sample population and stratified by age and severity of illness. Notes: (i) Severity of illness: (D) low (minor or moderate loss of function) versus (E) high (major or extreme loss of function). (ii) Percentages were adjusted for Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD) discharge weights to generate national estimates.

Figure 2.

Trends in surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR), and medical therapy (MT) from 2012 to 2016: stratified by sex, risk of mortality, hospital size, and hospital teaching status. Notes: (i) Risk of mortality: (C) low (minor or moderate likelihood of dying) versus (D) high (major or extreme likelihood of dying). (ii) Nonteaching hospital category in panel (G) includes nonteaching hospitals in urban area and any hospitals in rural area. (iii) Percentages were adjusted for HCUP-NRD discharge weights to generate national estimates.