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Background: Recent studies suggest that aortic valve replacement (AVR) remains underutilized., Aims: Investigate the potential role of non-referral to heart valve specialists (HVS) on AVR utilization., Methods: Patients with severe aortic stenosis (AS) between 2015 and 2018, who met class I indication for intervention, were identified. Baseline data and process-related parameters were collected to analyze referral predictors and evaluate outcomes., Results: Among 981 patients meeting criteria AVR, 790 patients (80.5%) were assessed by HVS within six months of index TTE. Factors linked to reduced referral included increasing age (OR: 0.95; 95% CI: 0.94-0.97; P < .001), unmarried status (OR: 0.59; 95% CI: 0.43-0.83; P = .002) and inpatient TTE (OR: 0.27; 95% CI: 0.19-0.38; P < .001). Conversely, higher hematocrit (OR: 1.13; 95% CI: 1.09-1.16; P < .001) and eGFR (OR: 1.01; 95% CI: 1.00-1.02; P = .003), mean aortic valve gradient (OR: 1.03; 95% CI: 1.01-1.04; P < .001) and preserved LVEF (OR: 1.59; 95% CI: 1.02-2.48; P = .04), were associated with increased referral likelihood. Moreover, patients assessed by HVS referral as a time-dependent covariate had a significantly lower two-year mortality risk than those who were not (aHR: 0.30; 95% CI: 0.23-0.39; P < .001)., Conclusion: A substantial proportion of severe AS patients meeting indications for AVR are not evaluated by HVS and experience markedly increased mortality. Further research is warranted to assess the efficacy of care delivery mechanisms, such as e-consults, and telemedicine, to improve access to HVS expertise., Competing Interests: Conflict of interest Dr. Elmariah is as a consultant for Edwards Lifesciences and Medtronic and receives institutional research funds from both Edwards Lifesciences and Medtronic. Dr. Wasfy reports no disclosures related to this study but acknowledges receiving support from the American Heart Association (18 CDA 34110215). Dr. Tanguturi is a co-principal investigator of a grant funded by Edwards Lifesciences for the institution. Additionally, Dr. Turchin reports receiving research support from Edwards Lifesciences. Dr. Coylewright is a consultant for Edwards Lifesciences, Boston Scientific, and Medtronic and has received institutional research funds from both Edwards Lifesciences and Boston Scientific., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Despite the rapid growth of aortic valve replacement (AVR) for aortic stenosis (AS), limited data suggest symptomatic severe AS remains undertreated., Objectives: This study sought to investigate temporal trends in AVR utilization among patients with a clinical indication for AVR., Methods: Patients with severe AS (aortic valve area <1 cm 2 ) on transthoracic echocardiograms from 2000 to 2017 at 2 large academic medical centers were classified based on clinical guideline indications for AVR and divided into 4 AS subgroups: high gradient with normal left ventricular ejection fraction (LVEF) (HG-NEF), high gradient with low LVEF (HG-LEF), low gradient with normal LVEF (LG-NEF), and low gradient with low LVEF (LG-LEF). Utilization of AVR was examined and predictors identified., Results: Of 10,795 patients, 6,150 (57%) had an indication or potential indication for AVR, of whom 2,977 (48%) received AVR. The frequency of AVR varied by AS subtype with LG groups less likely to receive an AVR (HG-NEF: 70%, HG-LEF: 53%, LG-NEF: 32%, LG-LEF: 38%, P < 0.001). AVR volumes grew over the 18-year study period but were paralleled by comparable growth in the number of patients with an indication for AVR. In patients with a Class I indication, younger age, coronary artery disease, smoking history, higher hematocrit, outpatient index transthoracic echocardiogram, and LVEF ≥0.5 were independently associated with an increased likelihood of receiving an AVR. AVR was associated with improved survival in each AS-subgroup., Conclusions: Over an 18-year period, the proportion of patients with an indication for AVR who did not receive AVR has remained substantial despite the rapid growth of AVR volumes., Competing Interests: Funding Support and Author Disclosures This study was funded by Edwards Lifesciences. Dr Inglessishas has received institutional research support from Medtronic, St. Jude Medical, and W.L. Gore and Associates; and is a proctor for Medtronic and Edwards Lifesciences. Dr Shah has received educational grants from Edwards Lifesciences, Medtronic, and Abbott Vascular; has received consulting fees from Edwards Lifesciences; has been a proctor for Edwards Lifesciences; and has been an advisory board member for Xenter. Dr Passeri has received institutional research support from Edwards Lifesciences; has been a speaker at an educational symposium sponsored by Medtronic; and has received consulting fees from Medtronic. Dr Kaneko has received consulting fees from Edwards Lifesciences, Medtronic, 4C Medical, CardioMech, Cook Medical; and has been a speaker for Abbott and Baylis. Dr Elmariah has received research grants from American Heart Association (19TPA34910170), National Institutes of Health (R01 HL151838), Edwards Lifesciences, Svelte Medical, Abbott Vascular, and Medtronic; and has received consulting fees from Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)