Striking Variations in Aortic Valve Replacement Rates and Use of Transcatheter Aortic Valve Implantation among European Nations

In Europe, female life expectancy is 82 years and male life expectancy is 75 years. According to some projections, women’s life expectancy will increase to 92.8 years by 2065, while men’s life expectancy will increase to 90.5 years [1]. Even if chronic diseases caused by the Western way of life might mitigate this predicted increase to some degree, the percentage of people over the age of 80 will continue to grow in the future. Since the prevalence of severe aortic stenosis is closely associated with age, increasing by nearly threefold between the seventh and eighth decades of life, the number of elderly patients presenting with aortic stenosis will continue to rise [2].

While all European nations face the same challenge of an increasing number of patients with severe aortic stenosis, less is known about differences in treatment rate and utilization of transcatheter aortic valve implantation (TAVI) across nations. The work by Rudolph et al. [3] in this issue of Cardiology provides intriguing insights into the substantial differences between European countries in the aggregate rate of aortic valve replacement (AVR), as well as use of TAVI in different age groups. Their comprehensive manuscript, which includes AVR data from twelve European countries from 2015 to 2020, sheds new light on this subject. Germany had the highest AVR rate, followed closely by Austria, France, Denmark, and Switzerland, while Spain and Poland had the lowest rates. In Switzerland and Finland, TAVI accounted for over 60% of all AVR; however, TAVI accounted for just 25% of procedures in Poland.

TAVI has revolutionized the treatment of symptomatic aortic stenosis. In 2011, the PARTNER Trial [4] demonstrated the efficacy of TAVI in high-risk, predominantly elderly patients. In this study, the mean age of TAVI patients was 83.6 ± 6.8 years. Therefore, it is plausible to anticipate positive outcomes with TAVI up to approximately 90 years of age. For nonagenarians, only registry and observational data exist, which are highly susceptible to bias, as patients with better health status are more likely to be referred for AVR. Due to their inherent bias, registry and observational data cannot be used as proof that a treatment increases quality of life or other patient outcomes. Therefore, uncertainty exists about whether nonagenarians receive the same benefits from TAVI as their younger counterparts. Given that randomized trials in this patient population are unlikely to be conducted in the near future, it is reasonable to perform TAVI in nonagenarians on an individualized basis taking into account patient symptoms, health status, remaining life expectancy, as well as patient preferences.

Current research focuses on optimizing and expediting the entire periprocedural process to reduce complication rates and permit early discharge, as each day of hospitalization, especially for the group of extremely elderly patients, increases the likelihood of irreversible muscle loss and immobility. The size of the required access sheath for TAVI has decreased substantially from 22 to 24 French in the first-generation to 14–16 French in modern devices, thereby decreasing the incidence of vascular complications and blood loss. With increased clinical experience and low-profile, less traumatic delivery systems, the transfemoral route is now feasible in more than 90% of patients [5]. At the same time, improved valve designs and implantation techniques have reduced the need for post-procedural pacemaker implantation. In addition, the ability to predict late atrioventricular conduction block based on pre- and post-procedural electrocardiogram findings has improved. This has allowed for a significant reduction in the number of days a patient must remain in the hospital after TAVI, with an increasing number of patients being discharged between 24 and 48 h after the procedure. The data presented by Rudolph et al. [3] are derived from a time period before the 2021 ESC/EACTS guidelines [6] for managing valvular heart disease recommend surgical aortic valve replacement (SAVR) for patients with symptomatic aortic stenosis aged under 75 years who are at low surgical risk and TAVI for patients aged 75 years or older as well as for younger patients who are at intermediate to high risk for surgical complications.

The descriptive nature of the paper’s findings precludes direct conclusions regarding the reasons for such striking differences in the overall performance of AVR and the adaptation of TAVI between the twelve European countries studied. Variations in reimbursement are a plausible, but likely not sole explanation for the observed intercountry variations. Early in its history, TAVR was markedly more expensive than SAVR, especially in cases with nontransfemoral alternative access and procedural complications. Additionally, the historically higher cost of TAVR than SAVR was substantially driven by the price of transcatheter heart valves being three times the price of surgical valves. In spite of the increasing global demand for TAVI, the price of TAVI prostheses has decreased over the past decades. In the USA, contemporary costs associated with TAVI are lower than for SAVR at all levels of surgical risk [7]. Current cost-effectiveness calculations for European countries found that TAVI is cost-effective compared to surgical AVR in most cases as well [8, 9]. As Indian and Chinese companies prepare to enter the global market, it is likely that prices will decline further in the future. This will enable less affluent health care systems to offer TAVI to a greater number of patients. Underdiagnosis of aortic stenosis may potentially contribute to variances in the total rate of AVR throughout Europe. Future research is required to determine which factors contribute most to the observed differences and how to optimize health care systems so that all patients receive a timely diagnosis and the best possible treatment for aortic stenosis.

Conflict of Interest Statement

The authors have no conflicts of interest to declare.

Funding Sources

The authors did not receive support from any organization for the submitted work.

Author Contributions

The commentary was written by M.K.G. in close cooperation with D.B. and W.R.

Funding Statement

The authors did not receive support from any organization for the submitted work.