MBS listing of TAVI expands access for patients with low risk severe aortic stenosis

MedTech News: Aortic valve stenosis is the most common valvular lesion in Australia, with a rising prevalence in line with the ageing population. From July 1, 2022, transcatheter aortic valve implantation (TAVI) will be funded on the Medical Benefits Scheme (MBS) for patients with symptomatic severe aortic stenosis (AS) at low surgical risk, 12 months after it was positively recommended by the Medical Services Advisory Committee (MSAC).

Since its introduction more than a decade ago, TAVI has emerged as the clinical standard of care in the public and private setting for high-risk surgical patients with severe aortic stenosis. However, multiple studies reveal TAVI also has greater short- and long-term benefits for low-risk patients, compared with surgical aortic valve replacement (SAVR).

According to Dr Ronen Gurvitch, Interventional Cardiologist and TAVI specialist at the Royal Melbourne Hospital and One Heart Cardiology, Melbourne, the MBS listing effectively expands access to minimally invasive, non-surgical treatment options for all severe AS patients.

“The treatment paradigm for AS has shifted. Traditionally, TAVI was only available to the oldest and frailest patients deemed too high risk to survive open heart surgery. However, data supports the use of TAVI as a therapy option for all patients with severe aortic stenosis,” said Dr Gurvitch.

A recently published multi-centre Australian cohort of 601 patients who underwent TAVI for severe symptomatic aortic stenosis between 2008 and 2018 found a trend to lower risk patients undergoing TAVI. They found mean patient age was 84, with 47% deemed low risk (STS <4%) and 40% intermediate risk (STS 4–7.9%) with only 12% deemed high risk. This cohort showed no difference in pacemaker insertion rates between groups, which represents an on-going hurdle for TAVI where pacemaker implantation and aortic insufficiency are considerably higher in patients who have undergone TAVI.

Interventional cardiologist talks advances in heart valve disease management and barriers to optimal patient care

“TAVI offers significant benefits over surgery, including reduced procedure time, less time in hospital, a shorter recovery period, lower risk of complications, improved quality of life, and extended life expectancy.

“Among severe symptomatic aortic stenosis patients, TAVI results in 46% lower rates of death, stroke and re-hospitalisation within the first year of the procedure, compared to SAVR. Data at two years following TAVI shows continued superiority over surgery, with 34% lower rates of death, stroke, and rehospitalisation,” Dr Gurvitch said.

“The MBS expansion of TAVI will better facilitate shared decision-making between Heart Teams and their severe AS patients, enabling us to choose the most suitable treatment based on anatomical factors, latest clinical evidence and patient preferences.”

Dr Gurvitch said aortic stenosis is both under-diagnosed and under-treated in Australia.

“Recent Australian data suggests that approximately 90% of patients with aortic stenosis are not receiving treatment. This is often because those living with aortic stenosis may not experience any noticeable symptoms until their blood flow is severely restricted, by which stage common symptoms of the disease are often wrongly attributed to the aging process,” said Dr Gurvitch.

“The risk of developing the disease increases with age, with those aged 65 years and above most affected. As such, cardiac auscultation should form part of an annual GP comprehensive cardiovascular disease risk assessment for every Australian over 65 years of age. Patients found to have any abnormalities should be referred to a cardiologist for further examination including echocardiography – the test of choice for heart valve disease,” Dr Gurvitch said.

CEO and founder of Hearts4Heart, Tanya Hall, Melbourne, welcomes the additional MBS item but believes more needs to be done to address the nation’s rising rates of undiagnosed heart valve disease.

“The availability of TAVI on Medicare means that all patients with severe forms of AS now have access to a minimally invasive, non-surgical approach to aortic valve replacement, improving patient choices,” said Ms Hall.

“However, the number of people living with aortic stenosis in Australia predicted to increase over the next 30 years, particularly among those aged over 75 years,12 placing a significant burden on Australia’s healthcare system and economy, given our ageing population. Offering minimally invasive treatments, such as TAVI, to more people aged 65 years and over, could save the public purse AUD 117 million per annum,” Ms Hall said.

Heightening awareness among older Australians to increase patient identification, and subsequent treatment is a critical first step, which is why we are also advocating for cardiac auscultation to be added to the existing heart check MBS item this year.”