Over the past 2 decades, the proportion of patients who need AVR and are untreated has remained unchanged, representing a major unmet need in the field of cardiology. Investigators from the Mass General Brigham academic hospital network assessed temporal trends in AVR use during an 18-year period (2000-2017) among patients with a clinical indication for the procedure. They found that fewer than 50% of patients spanning all AS subgroups receive AVR. They also found that 6150 of 10,795 patients included in the study had an indication or potential indication for AVR, with only 2977 receiving it. The investigators noted that in all AS subgroups, the number of patients who did not receive AVR is substantial.

AVR exhibits survival advantage in high- and low-gradient normal LVEF cohorts, yet substantially fewer patients with low-gradient AS are referred for and receive AVR vs. patients with high-gradient AVR. In the study, more than 50% of patients with symptomatic severe aortic stenosis (SSAS) did not receive AVR, with only 1 of 3 patients with high-gradient AS and a Class I indication for AVR receiving the procedure. Factors underlying why patients with indications for AVR don’t have the procedure may include advanced age, low-gradients , and multiple comorbidities. It was also found that when the provider ordering the TTE is a cardiologist, the chances that the patient will receive AVR are higher.

It is important to note that mortality from a prolonged waiting time for AVR is higher than AVR operative mortality, and many patients die while waiting for the procedure. In other words, AVR should be performed on a semi-urgent basis when indicated.

What are your thoughts on how to improve urgent referral/treatment of SSAS patients for AVR, including those who are in their 80s or 90s or with low-gradient subtypes, as these patients are least commonly referred with urgency?