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2yr
Exigency of TAVR referrals

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?

  • 2yr
    The patient recovery of TAVI is truly remarkable . Given the solid clinical outcomes , the word is out and patients are requesting this procedure over an open heart intervention
  • 2yr
    Patients with low gradient severe aortic stenosis will have poor long-term survival when treated with optimal medical therapy alone. Aortic valve intervention can improve survival for these patients. Expert consultation and discussion between a patient's medical doctor, cardiologist, and a Heart Team is essential for identifying appropriate elderly patients for valvular intervention. Internal medicine and family practice physicians along with patients themselves need to be aware that transcatheter aortic valve replacement is a great therapeutic option for elderly patients with co-morbidities who are considered a high surgical risk or with contraindications to open heart surgery.
  • 2yr
    I think we can do a better job of making the echo reports more informative, particularly if we know that the ordering physician/provider is not a fellow cardiologist. It doesn't take but a moment for a cardiologist to sift through the numbers in the "fine print" but these things mean nothing to non-cardiologists. Also, in all honesty, I think cardiologists as a whole are doing a better job of identifying low-flow/low-gradient AS and atypical presentations and this needs to become universal. A very clear impression of an echo read, even if it has to say "cardiology referral recommended for further evaluation of severe/possibly severe aortic stenosis", particularly if this is not a serial echo and suggests a new diagnosis.
  • 2yr
    Clearly education is a critical linchpin for this cohort of patients. While it is understandable, that high and intermediate level gradients and risk, patients will benefit, it’s naturally a bit more obtuse to a primary care, physician, or an internist, that low gradient AS has similar mortality and mobility.
    I think the echocardiographer could move this needle by recommending a referral to a structural cardiologists. In my hospital we have adopted a box on the echo report that we can click that says ‘Refer to a structural cardiologist?’ Then automatically a referral is sent.
  • 2yr
    it is more detection and referral. it is more education of other ordering providers.
  • 2yr
    I believe that many patients have family members acting as medical decision makers as they get older and many of these relatives assume that the only options are medical management vs surgery without being aware of the TAVR option. Many of them assume their octagenarian relative would fare poorly with surgery and thus may not be proactive with keeping appointments for follow up pre procedure echocardiographic surveilance studies.
    I believe that better education of families and waiting room literature may introduce the decision makers to the relatively new realities of available procedures.
  • 2yr
    If the referring physician for the echocardiogram is a primary care doctor, the echocardiographer has to be more direct with recommendations. The hands off approach, just reporting the AVR gradients, will lead to continued under-estimation of low flow AS, and under-treatment of low-flow AS. Recommending a non-contrast CT to see if calcification of the valve is severe, could be part of the echo report. Further, recommending cardiology follow up in the impression/plan of the echocardiogram will go a long way to bridge this gap. The primary care doctor just doesn't know what they do not know, and can't possibly be routinely up to date on things as complex as low flow AS.
  • 2yr
    There are two important elements. One is education. The primary care physicians need to know that low gradient patients may still have severe aortic stenosis and the primary care doctors need to have a lower threshold to refer patients to Cardiology. The second issue is access. Cardiologists just don’t have enough appointments. Specialty nurse practitioners or PAs need to be trained focusing specifically on valve disease. They can evaluate and triage patients towards the cardiologist for Tavr or surgical aortic valve replacement as warranted.
  • 2yr
    We are seeing increasingly that severe aortic stenosis despite a low gradient is a real clinically significant entity which deserves treatments. Intervening earlier especially in the context of newer techniques can be very advantageous in preventing morbidity and mortality soon down the line.
  • 2yr
    Educating primary care providers and patients that most cases of aortic stenosis can be treated percutaneously is key. Many PCPs don’t order echocardiograms or patients and their families decide why bother because the patient would not want open heart surgery. Also, it is important to have an appropriate team including sonographers, cardiologists, and structural heart team to review the studies and have the patient evaluated for symptoms and/or low flow low gradient AS.
  • 2yr
    I have recommended formal cardiology evaluation whenever me or my associates determine that an echocardiogram we read demonstrate significant aortic stenosis
  • 2yr
    Recognizing the sings and symptoms of aortic valve stenosis with a good echocardiographic assessment of the mean gradient and vale area estimation is the key. Low flow low gradient AS may lead suspicion for ATTR amyloidosis as well. Refferal to Heart Valve Team for consideration fo SVAR vs TVAR.
  • 2yr
    At the front end, there needs to be a suspicion that leads to an echocardiogram, either from a PCP or the patient themselves. A good echo department with excellent sonographers will then identify AS fairly easily, including a suspicion for low gradient low output varieties. The next key is to also have a well staffed and respected valve team, appropriately aggressive and appropriately conservative depending on the patient with options for both SAVR and TAVR.
  • 2yr
    Not too hopeful AI will be helpful anytime soon particularly away from tertiary care centers.
    With us, almost all patients of this type are referred to cardiology, whether for evaluation of sx or a murmur or to obtain an echo. I suspect low gradient AS is mostly already seen by cardiology, and would probably be referred to TAVR as they are presumably hi risk patients.
    Would therefore primarily reach out to cardiologists to review the workup and care of these patients
  • 2yr
    I agree with the last commenter that using AI algorithms can improve the detection of severe LFLG AS. In addition, increasing overall education of this phenomenon with PCPs as well as cardiologists would improve the likelihood of patients receiving appropriate treatment.

    In our echo lab we make it a point to mention the potential presence of LFLG AS on all patients that have low DVI or low AVA. Hopefully, this alerts PCPs to consider severe AS if clinically appropriate and refer patients accordingly.
  • 2yr
    I think that the best thing to do would be to have artificial intelligence scrape the reports for a given healthcare system with regards to finding patients with a low stroke-volume index and a low dimensionless index and flag that for review by either the primary physician who ordered the test or a member of the structural valve team in order to reach out and potentially "self-refer." Beyond that, education around the definition of low-flow low gradient aortic stenosis and pseudo pseudo aortic stenosis would be beneficial, but at times, primary care physicians are ordering these tests and do not fully understand how to recognize this, which is then on us as echo readers to point out and potentially even call the ordering physician to let them know directly that there is an issue.
  • 2yr
    Education of the family practice and internal medicine physicians in the community is vital. Having ready access to cardiologists for phone consultation would be helpful. These physician should be encouraged to reach out to the Cardiology colleagues when there is questions about the management of an aortic valve stenosis patient. A team approach to the treatment of this disease is essential.
  • 2yr
    Recognition that a heart valve team at a valve center is available to the PCP or ANP and has the ability to assess SSAS whether related to high gradient of LFLG AS is important first step for referrals. Having a network available to the PCP is so important in getting patients in for consultation.
  • 2yr
    The most appropriate thing to improve referrals is education of PCPs and Cardiologists. Knowing that PLF severe AS is a very prominent and common phenotype of AS is crucial here. Many see this phenotype and underestimate the degree of AS. If one examines the patient closely, PLF severe AS sounds like severe AS (no S2 at the apex and a harsh mid to late peaking SEM). It is all about awareness and education.
  • 2yr
    Recognizing that the valve area may be correct and the patient has severe as with low gradients is key. Having a way to easily refer to a structural heart team is huge ! It is literally a few clicks and the team takes care of seeing the patient and referring for TAVR or SAVR.

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