Cedars-Sinai’s Joanna Chikwe, MD regarding the TAVR’s shift to younger and healthier patients, despite SAVR’s outcomes advantage.

Surgeries & Interventions

SAVR’s Value in the TAVR Era

Procedure trends certainly suggest that we’ve entered the TAVR era, but a pair of new studies show that surgical aortic valve replacement (SAVR) is a far better option for many younger and healthier patients who are increasingly seen as TAVR candidates.

In the first study presented at The Society of Thoracic Surgeons’ 2024 Annual Meeting, researchers analyzed outcomes from 37k California-based patients who underwent SAVR or TAVR between 2013 to 2021…

• Of the 2,360 patients under the age of 60, 22% received TAVR and 78% received SAVR.
• However, the ratio of under-60 patients who underwent TAVR increased from 7% in 2013 to 62% in 2021.

TAVR’s under-60 surge appeared to lead to worse overall outcomes, as SAVR patients had significantly better 5-year survival rates (98% vs. 86%) even when comparing a propensity-matched population (93% vs. 88%).

Given these 5-year survival rates, the researchers called for more RCTs and coverage determinations to support aortic valve replacement decision making, especially as TAVR continues to trend towards younger and healthier patients.

A second study in The Annals of Thoracic Surgery further detailed SAVR’s rapid volume declines, while highlighting certain patients who remain better off with surgery. The researchers analyzed 200k nationwide adults who underwent SAVR between 2011 and 2022, finding that…

• Annual SAVR volumes decreased by 45% (19,560 to 10,851).
• The proportion of SAVR patients increased in the <65yr patient group (26.2% to 54.5%), but declined among 65-79yr (49.2% to 43.6%) and ≥80yr patients (24.7% to 1.9%).

Much of these SAVR declines occurred in patients with tricuspid aortic valves (from 84.5% to 55% of total SAVRs), while SAVR ratios increased among patients with bicuspid aortic valves (from 15.5% to 45%). 

That’s a positive trend given that <80yr SAVR patients with bicuspid aortic valves also had better-than-expected mortality rates. It was also strong enough evidence for the authors to encourage changing the STS-ACSD risk model based on aortic valve morphology, and to suggest that SAVR should remain the preferred therapy among <80yr patients with bicuspid aortic valves.

The Takeaway

The “transcatheter era” has brought a surge in TAVR procedures that’s largely outpaced medical evidence and consensus guidelines (which recommend SAVR <65yrs). These new studies suggest that many TAVR patients would have enjoyed better outcomes with SAVR, and reveal a need for revamped trials to clarify which patients would be better off with SAVR or TAVR.

Nothing Is More Expensive Than a Missed Opportunity

The emergence of AI CAC detection and new CVD treatments could transform preventative CVD care. Check out this Johns Hopkins editorial in JACC detailing how solutions like Bunkerhill Health’s Incidental CAC algorithm can create opportunities for more effective preventative CVD care, but only if providers seize that opportunity.

Accurately Measuring Heart Rate Variability

Heart rate variability measurement and analysis involves two critical elements – the ability to accurately discern the R wave in noisy environments, and using the correct analysis method for a given application. Check out how Monebo’s Kinetic HRV ECG Algorithm excels at both of these essential tasks.

HeartFlow FFRCT’s Real World Impact

See how HeartFlow FFRCT Analysis significantly improved NHS England’s patient outcomes and clinical efficiency in a massive real world implementation across 90k patients in this presentation by Newcastle University’s Professor Vijay Kunadian.

The Wire

• Boston Scientific’s PFA Approved: AFib pulsed field ablation reached another major milestone this week, following the FDA approval of Boston Scientific’s Farapulse PFA system for paroxysmal atrial fibrillation. The approval comes about six weeks after Medtronic’s PulseSelect became the first FDA-approved PFA system, which covered treatment of both paroxysmal and persistent AFib. PFA systems use electroporation (short electrical pulses) to achieve pulmonary vein isolation, and are seen as safer and faster than current thermal ablation techniques.

• Heart Disease Unawareness: If it seems like more than half of your patients aren’t aware that heart disease is the number one cause of death, that might actually be normal. An AHA-funded 2023 Harris Poll survey showed that only 49% of respondents identified heart disease as the leading cause of death in the U.S., while 16% said they didn’t know the leading cause and 18% said it was cancer.

• Biotronik on the Block: Reports out of Germany suggest that Biotronik is considering selling its €400M Stents and Balloon Catheters business for up to €1B, as the company looks to focus on its core operations and pay down its €600M in debt. Biotronik has reportedly enlisted Goldman Sachs to guide the transaction, and insiders expect that the unit will be acquired by financial investors rather than by another major medtech player.

• RDN Controls the Costs of Uncontrolled HTN: Radiofrequency renal denervation (RF RDN) gained traction as a cost-effective therapy for uncontrolled hypertension with an incremental cost-effectiveness ratio of £13,482 per QALY gained in a UK-based study. RF RDN model projections have also shown a reduction of almost 5 mmHg in office SBP, which can be expected to lead to a 20% reduction in stroke and 12% reduction in MI over ten years.

• Another Florida Private Equity Acquisition: In another sign that Florida has become America’s battleground state for private equity-driven cardiology practice acquisitions, First Coast Cardiovascular Institute (11 locations, 38 providers) acquired neighboring Jacksonville-based practice CardioHealth. The acquisition was driven through the private equity-owned platform, Cardiovascular Logistics, which launched in early 2023 and has since made at least six practice acquisitions. Cardiovascular Logistics joins Cardiovascular Associates of America as the two leading PE-funded forces behind Florida’s cardiology practice consolidation.

• Philips’ Mini 3D TEE: Philips launched a miniaturized 3D transesophageal echocardiography ultrasound transducer designed for use in settings where larger TEE probes aren’t appropriate, like in children or ICU cases. The FDA-cleared X11-4t Mini 3D TEE transducer delivers the value of high-quality 3D cardiac imaging for more fragile patients and can reduce complications from prolonged transesophageal imaging during structural heart procedures.

• Top Diabetes CV Risk Biomarkers: A systematic review of 416 CV biomarker studies in Nature identified 13 biomarkers that could improve CVD risk prediction in type 2 diabetes patients. The review found that NT-proBNP has the most short-term potential for predicting cardiovascular risk, while TnT, TyG, and GRS-CHD also showed longer-term promise.

• HF Hospitalization Disparities: Black Medicaid patients are far more likely than White patients to be subject to “preventable hospitalizations” (e.g. for heart failure, COPD, or diabetes), according to a new Urban Institute report. In 2019, nearly 13% of Black Medicaid patients with previously diagnosed heart failure experienced a potentially avoidable hospitalization (vs. 7% of their White counterparts), highlighting a glaring need to improve outpatient care for chronic conditions among Black enrollees.

• Karoo Health’s VBC Validation: Cardiology value-based care enablement company Karoo Health released results from its first proof of concept study, showing solid VBC progress at its partner practices. Cardiology practices that adopted the Karoo platform were able to convert 70% of their eligible patients to the Karoo VBC model over the six month study period, far better than the 25% to 30% rates that Karoo says is typical with other VBC companies. Once enrolled, 95% of those patients became engaged with the digital platform, and 21.7% of their unnecessary ED visits were avoided.

• Changing Arteries, Continuing Surveillance for TGA: In 1,359 patients who underwent an arterial switch operation (ASO) for various forms of transposition of the great arteries (TGA), a study in JACC showed that the mean root annulus, sinuses of Valsalva, and STJ diameters all grew over 30 years. For the entire study population, the sinuses of Valsalva and neo-aortic annulus were particularly enlarged with z-scores >2 by about 5 years post-ASO. The authors emphasize the need for long-term surveillance of the neo-aortic root after ASO in this unique patient population.

• Financial Distress Boosts Hospital M&A: US hospital mergers and acquisitions accelerated in 2023, with ongoing financial challenges helping drive 65 M&A transactions totaling $38.4B (up from 53 the year prior). According to Kaufman Hall, financial distress accounted for 28% of transactions – almost double 2022’s rate – and is impacting a growing number of larger systems (financial distress is historically more common in smaller hospitals).

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The Resource Wire

• Measuring True Cardiac Risk: How can AI help physicians “see” beyond conventional lipid profiles? Tune in to this on-demand webinar showcasing how Cleerly’s AI-QCT solution complements conventional approaches to evaluating heart disease risk factors, and improves coronary artery disease diagnosis and heart attack risk assessments.

• PIA’s Post-Processing Solution: Advanced cardiac imaging often calls for a time-consuming post-processing step, requiring costly software, hardware, and training. See how PIA provides this post-processing at lower cost, improved consistency, and greater efficiency. 

• Where to Go for Cardio AI? TeraRecon’s Cardio Suite is a collection of hand-selected, vendor-neutral Cardiology AI algorithms that aid in the analysis and interpretation of echocardiograms and chest CTs. Learn about TeraRecon’s AI offering and how they improve efficiency and accuracy here.

• Diagnosis Beyond the Hospital: It’s increasingly clear that healthcare is expanding beyond hospital walls, and recent evidence from Us2.ai suggests that AI-enabled cardiac ultrasound could help drive that expansion. Read these editorials by Izabella Uchmanowicz, RN, PhD and Prof. Blanche J Cupido, MBChB to see how Us2.ai-enabled and nurse-operated mobile ultrasound might both improve and expand heart failure diagnosis.

• Preparing for the Future of Cardiovascular Data and Analytics: There’s plenty of short term benefits to cardiology data analytics, but it’s just as important for providers to make sure they’re ready for the future of cardiology analytics. This Change Healthcare article with Dr. Jennifer Hall, chief of data science at the American Heart Association, examines what technology leaders can do today to facilitate their future advancements in cardiovascular data and analytics.