An updated MBS listing allows more patients access to heart valve treatment option.
Aortic stenosis remains one of the most common valvular conditions in Australia.1,2 Once patients develop severe stenosis, they have a life expectancy that is worse than many cancers.3 Close monitoring and early treatment of aortic stenosis has been shown to improve outcomes for these patients.3
With Australia’s aging population, the number of patients who will require treatment is likely to increase dramatically over the next 5-10 years.4
Transcatheter aortic valve implantation (TAVI) has been an effective, less invasive option for patients with severe aortic stenosis.
The international randomised controlled trials across high, intermediate and low-risk patient groups have demonstrated that TAVI has equivalent outcomes to surgery in the short to medium term. This is now reflected in the latest European Association for Cardio-Thoracic Surgery (EACTS) and European Society of Cardiology (ESC) Guidelines for the management of valvular heart disease.
Medicare has typically operated on a 12–18-month delay following such guideline changes.5
Until recently, Medicare only funded TAVI in patients deemed at high surgical risk. However, in March 2022 the TAVI Medicare Benefits Schedule (MBS) listing was updated to include patients at intermediate risk from surgery.
From July 1, 2022, TAVI became funded on the MBS for patients living with severe symptomatic aortic stenosis at low surgical risk, 12 months after it was positively recommended by the Medical Services Advisory Committee (MSAC).
Deciding between surgery and TAVI for patients with severe aortic stenosis remains a multidisciplinary team (Heart Team) decision with input from cardiologists, surgeons, and physicians.
Current guidelines suggest that those over 75 years should have TAVI, given lack of valve durability and patient outcome data beyond 5-8 years.5
Aside from age, factors such as frailty, peripheral access, other valvular disease and concomitant coronary disease often impact the decision to opt for surgery or TAVI.
Patient cohorts not included in TAVI randomised controlled trials include those with bicuspid aortic valves, pure aortic regurgitation, and aortopathies whose outcomes following TAVI remain uncertain.
From a patient perspective, TAVI has a very short recovery time compared to surgery, with some centres doing the procedure as day surgery for select patients. Iterative improvements in the valve technology and procedural technique have meant this is now a 30- to 45-minute procedure under light sedation with local anaesthetic.
The need for permanent pacemaker (PPM) post-TAVI remains the most common complication, although risk of this is decreasing. The incidence rate is 6-20%, with balloon-expandable valves having the lowest incidence.6
The prognostic impact of requiring a PPM post-TAVI remains uncertain, although any detrimental effect will likely occur in younger patient cohorts. Other complications such as death and stroke are comparable to surgery, with renal dysfunction and bleeding being understandably lower in the TAVI cohorts.7
Keeping TAVI complication rates low requires adequate volume for both sites and operators.6
This is important as all centres involved in the randomised controlled trials were large centres which showed equivalence to surgery.
In Australia and New Zealand, TAVI centres and operators are required to perform a minimum number of cases per year to maintain accreditation. This is currently unique to transcatheter valve intervention and will likely be the mainstay for all new cardiology procedures moving forward.
The recent MBS changes allow intermediate risk patients with severe aortic stenosis to be treated with TAVI.
This is already established in many countries worldwide and inclusion of low-risk patients will likely follow later this year.
TAVI has brought about a new era in valve treatment technology after more than 50 years of surgery being the only option.
Although long-term data is still lacking, the effectiveness of TAVI in more elderly cohorts is established and the multidisciplinary approach to not only patient selection but holistic care continues to ensure high quality outcomes in Australia.
Dr Ross Roberts-Thomson is a cardiologist who specialises in the management of valvular heart disease at Royal Adelaide Hospital. He is also a senior clinical lecturer at the University of Adelaide and the Royal Adelaide Hospital.
References
- Nathaniel, S., S. Saligram, and A.L. Innasimuthu, Aortic stenosis: An update. World J Cardiol, 2010. 2(6): p. 135-9.
- Strange, G., et al., Uncovering the treatable burden of severe aortic stenosis in Australia: current and future projections within an ageing population. BMC Health Services Research, 2021. 21(1): p. 790.
- Barnhart, G.R., Martin, R. P., Thomas, J. D., & McCarthy, P. M., The Need for Echocardiography Alerts for Aortic Stenosis: The Time Has Come. Journal of the American Society of Echocardiography, 2020. 33(3): p. 355-357.
- Adams, H., et al., The Low-Risk TAVI Trials for Severe Aortic Stenosis: Future Implications for Australian and New Zealand Heart Teams. Heart Lung Circ, 2020. 29(5): p. 657-661.
- Vahanian, A., et al., 2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). European heart journal, 2022. 43(7): p. 561-632.
- Russo, M.J., et al., Case Volume and Outcomes After TAVR With Balloon-Expandable Prostheses: Insights From TVT Registry. J Am Coll Cardiol, 2019. 73(4): p. 427-440.
- Tamburino, C., et al., Comparison of complications and outcomes to one year of transcatheter aortic valve implantation versus surgical aortic valve replacement in patients with severe aortic stenosis. Am J Cardiol,, 2012. 109(10): p. 1487-93.
