Associate Professor Dion Stub, Hope For Hearts and MEDD contributor, shares his views on the challenges for patients with aortic stenosis accessing new treatment technologies.

Aortic stenosis is a common, potentially terminal valvular condition which affects hundreds of thousands of elderly Australians each year.

Typically, a multi-disciplinary heart team will conduct a thorough evaluation of a patient to determine the right treatment option – surgical aortic valve implantation(SAVR) or transcatheter aortic valve implantation (TAVI).

Mounting evidence shows that Transcatheter Aortic Valve Implantation (TAVI) may be a better option than Surgical Aortic Valve Replacement (SAVR) for otherwise healthy seniors with aortic stenosis.

Leading expert interventional cardiologists are therefore calling on regulatory bodies to update Australia’s outdated aortic stenosis guidelines to make TAVI more easily available.

Comparing TAVI and SAVR

TAVI is more cost-effective than SAVR and just as clinically effective. It’s far less invasive, avoids the associated risks of surgery in an older cohort, and delivers similar health outcomes with a shorter hospital stay and faster recovery. And given a choice (which the system currently denies them) most patients would prefer it to open heart surgery.

Understandably, a healthy 78-year-old with no other major health problems would rather have a less invasive procedure, a shorter hospital stay and a faster recovery.

Associate Professor Dion Stub an Interventional Cardiologist of Melbourne was recently published in the International Journal of Cardiology for his study on Cost-effectiveness of transcatheter aortic valve implantation compared to surgical aortic valve replacement in the intermediate surgical risk population.

Dr Dion comments, my patients look at me with shock and confusion when I tell them they are too healthy to have the percutaneous procedure through the femoral artery so must have open heart surgery instead. It’s baffling.

Recently, my colleagues and I performed a contemporary cost-effectiveness analysis of current-generation TAVI versus SAVR from the Australian healthcare system perspective using data from the PARTNER S3i trial.

We found that TAVI was initially more expensive due to the cost of the transcatheter valve. But those costs were offset by a shorter hospital stay, meaning the overall costs were lower for TAVI. Over 10 years, with 5% annual discounting, we estimated that costs were $50,515 AUD in TAVI and $60,144 AUD in SAVR.

That should convince the health economists. But it’s the patients who really matter. In our analysis, TAVI produced 0.33 more life years and 0.31 more QALYs than SAVR.

TAVI is therefore a highly cost-effective option compared to SAVR in intermediate-risk patients with severe aortic stenosis.

So, why isn’t it more readily available in Australia?

Australia’s Current Aortic Stenosis Guidelines

TAVI would be a suitable clinical option for the vast majority of patients with aortic stenosis. The Therapeutic Goods Association has approved TAVI for intermediate risk patients with the third-generation valve, but that is yet to cross over to the Medicare Benefits Scheme schedule which only allows it for high-risk surgical patients.

That means cardiologists can offer TAVI to intermediate-risk patients in public hospitals but not in the private system. Many end up shunting private patients into the public system so they can have the procedure.

What Needs to Change?

We should be rightly cautious about changing proven practice but there comes a time when that wise caution slips into a resistance to change that’s ultimately unfair to patients.

We know behaviour change is hard for patients but it’s just as hard for clinicians and policymakers. Australia’s former Chief Scientist, Professor Ian Chubb, once noted that:

Today, it takes a minimum of 6.3 years for evidence to reach reviews, papers and textbooks. On average it then takes an additional 9.3 years to implement evidence from reviews, papers and textbooks into clinical practice.

That means it takes over 15 years for research knowledge to become clinical practice. It’s far too long for the 78-year-old who hates the thought of heart surgery when there’s an equally viable alternative that involves no general anaesthesia, takes less than an hour and means they’ll be home in two or three days without significant wounds.

It’s time for TAVI to be treated like any other proven procedure. Interventional cardiologists should be able to offer TAVI to eligible patients based on their clinical needs, not forced to deny it due to an outdated guideline that fails patients.

Associate Professor Dion Stub Associate Professor Dion Stub is a clinician, interventional cardiologist and a specialist in structural heart procedures. Dion has a particular interest in treating the cardiac emergencies of myocardial infarction and cardiac arrest. Dion has published over 100 peer reviewed manuscripts and has been internationally recognised for his research. He has delivered multiple presentations on both cardiac emergencies and structural heart intervention. Dr Stub currently holds the prestigious National Heart Foundation Fellowship to support his clinical research. He is an Associate Professor with Monash University and Baker IDI Heart and Diabetes Institute, medical advisor to Ambulance Victoria and representative on Australia Resuscitation Council. Learn more