Evolution of TAVR in Denmark May Have Implications for Other Countries

Patterns of transcatheter aortic valve replacement in Denmark, an early adopter of the technology, provide a glimpse at what the future may hold for other countries where it has been more recently introduced.

“Overall, the total number of AVR procedures increased [by] more than 50% over the past 10 years,” write Ole De Backer, MD, PhD (Rigshospitalet, Copenhagen, Denmark), and colleagues. They ascribe the increase to aging of the population as well as increased awareness and referrals for TAVR in the elderly.Evolution of TAVR in Denmark May Have Implications for Other Countries

Specifically, TAVR penetration increased from 20.1% in 2011 to 36.4% in 2015, with a trend toward more low/intermediate-risk patients getting TAVR. At the same time, the rate of SAVR remained stable, but there was a downward shift in the age at which surgical prostheses were used.

The study, published online recently in JACC: Cardiovascular Interventions, examined treatment of severe aortic stenosis from 2005 to 2015 using data from the WebPATS East Denmark Heart Registry.

In 2015, researchers report, TAVR—first introduced in Denmark in 2007—accounted for 36.4% of all aortic valve replacement procedures. Data from the registry also show a clear evolution in TAVR patterns from large concentrations of high-risk patients in the early years, to lower risk patients in later years. Compared with 2008-2009, for example, when nearly 40% of TAVR patients had an STS score > 8, only 15% of TAVR patients in 2013-2014 had such a high score.

Among the SAVR patients, the age at which surgical prostheses were implanted fell from 68 years in 2005-2006 to 61 years in 2013-2014. Additionally, comparison of mortality for TAVR and SAVR populations aged 70-85 years with an STS risk score < 6 showed no difference in death rates.

Larger Share of a Larger Pie

“In Denmark, indications have been progressively liberalized and age > 80 alone is considered an indication for TAVR,” comment John G. Webb, MD and Sandra Lauck, PhD (both of St. Paul’s Hospital and the University of British Columbia, Vancouver, Canada), in an accompanying editorial. Comparing Denmark with Canada, they note that British Columbia has seen a 100% increase in the last decade in the total volume of AVR—two times the increase reported for Denmark.

“Although one might attribute the increase in AVR solely to an increase in TAVR, this not the case,” Webb and Lauck observe. “Surprisingly, growth in [British Columbia] over this period has been numerically similar for both SAVR and TAVR, likely attributable to increased awareness, referral, and willingness to perform surgery in aortic stenosis patients. They further suggest that “as indications become more liberal, TAVR is beginning to consume a larger share of what has become a larger pie.”

With the trend toward greater use of TAVR predicted to continue in the coming years along with growing demand for the technology from both patients and physicians, the editorialists say, it will become more and more important to scrutinize TAVR and SAVR similarly in terms of how they affect issues of quality of life, resource utilization, and cost, among factors.

 


Sources:
  • De Backer O, Luk NHV, Olsen NT, et al. Choice of treatment for aortic valve stenosis in the era of TAVR in eastern Denmark (2005-2015). J Am Coll Cardiol Intv. 2016;Epub ahead of print. 
  • Webb JG, Lauck S. Transcatheter aortic valve replacement in transition. J Am Coll Cardiol Intv. 2016;Epub ahead of print. 

Disclosures:

  • De Backer reports serving as a proctor for St. Jude Medical. 
  • Webb reports consulting for Edwards Lifesciences, St. Jude Medical, and Abbott. 
  • Lauck reports consulting for Edwards Lifesciences. 

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