When Is the Optimal Time for Aortic Valve Replacement? Impact of Acute Valvular Syndrome on Outcomes and Costs

According to the clinical presentation before aortic valve replacement (AVR), a new classification has recently been proposed: stable valvular syndrome (SVS), progressive valvular syndrome (PVS), and acute valvular syndrome (AVS). The latter is characterized by New York Heart Association (NYHA) class III–IV dyspnea, hospitalization for heart failure (HF), syncope, or shock.

The aim of this study was to evaluate the clinical, economic, and resource utilization impact according to the presentation at the time of AVR, whether surgical (SAVR) or transcatheter (TAVR).

Data from the Market Clarity (Optum) registry between 2017 and 2023 were analyzed. A total of 24,075 adults from the United States with aortic stenosis (AS) who underwent AVR (56% TAVR, 44% SAVR) were included, excluding those with moderate or severe aortic regurgitation. Of these, 270 (1.1%) were SVS, 10,195 (42.3%) PVS, and 13,610 (56.5%) AVS.

Patients with AVS were older (72 ± 11.7 years), had more comorbidities (Elixhauser score 10.1 ± 3.3), and greater frailty (HFRS 18.9 ± 12.2). Women represented 38.9% of the cohort.

The primary endpoint was mortality and hospitalization for HF at one year. Secondary endpoints included total costs (index hospitalization + one-year follow-up) and healthcare resource utilization.

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At one year, mortality was 11% in AVS, 4.7% in PVS, and 1.5% in SVS (HR 2.93; 95% CI 1.1–7.8; p = 0.03). HF hospitalization occurred in 12.8% of AVS, 4.2% of PVS, and 1.6% of SVS (HR 4.15; 95% CI 1.6–11.1; p < 0.01). The composite endpoint of death or HF occurred in 20.2% of AVS versus 2.7% of SVS (HR 3.6; 95% CI 1.7–7.6; p < 0.001).

Total costs (procedure + one year) were USD 146,309 for SVS, USD 173,719 for PVS, and USD 182,576 for AVS (p < 0.001), with adjusted differences of +USD 27,410 and +USD 36,267 compared to SVS. The mean hospital stay increased progressively: 6.5 days (SVS), 7.3 (PVS), and 8.6 (AVS).

The readmission rate was 0.81, 1.05, and 1.27, respectively (p < 0.001). Patients with AVS had nearly five times more HF hospitalizations (IRR 4.86; 95% CI 1.9–12.6; p < 0.001) and about seven times more hospital days due to HF (1.93 vs. 0.28 days; p < 0.001).

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Both TAVR and SAVR showed the same gradient of increasing costs and hospitalization duration with greater syndrome severity, although the economic difference was more pronounced in the TAVR group.

Conclusion

Acute valvular syndrome was the most frequent presentation (56%) and was associated with a significant increase in mortality, hospitalizations, costs, and healthcare resource use following AVR.

Patients with stable valvular syndrome had the best clinical and economic outcomes. These findings support early intervention in severe aortic stenosis, to prevent progression to AVS and its adverse impact on survival and healthcare expenditures.

Original Title:  Acute Valve Syndrome Before Aortic Valve Replacement: Impact on Clinical Outcomes, Health Care Costs, and Resource Use.

Reference: Philippe Généreux et al. Journal of the American Heart Association. 2025;14:e043486. DOI: 10.1161/JAHA.125.043486.