National Trends in Aortic Stenosis Mortality in the Pre- and Post-TAVR Eras in the United States, 1999 to 2023
Key Summary
- National aortic stenosis mortality is declining, with the greatest benefit in women—likely due to superior hemodynamics and reduced patient–prosthesis mismatch vs SAVR.
- Rising mortality in ages 55 to 64 suggests underdiagnosis and delayed referral, particularly in bicuspid or metabolically driven AS.
- Disparities in treatment persist—early echocardiography and timely referral to TAVR-capable centers remain critical to improving outcomes for all populations.
In this interview with JIC, Dr Saad Ur Rahman discusses findings from “National Trends in Aortic Stenosis Mortality in the Pre- and Post-TAVR Eras in the United States 1999–2023,” presented at the 2026 American College of Cardiology Scientific Sessions, highlighting mortality trends, persistent disparities, and the clinical implications for early detection and equitable access to TAVR.
Lahey Hospital and Medical Center
1. You found that mortality declined more rapidly in women than in men. What factors—biological, clinical, or access-related—do you think might explain this sex-based difference?
Women historically have had higher operative risk with surgical valve replacement (SAVR) due to smaller annular size, older age at presentation, and higher frailty burden. The expansion of transcatheter AVR (TAVR) likely benefited women disproportionately because the transcatheter approach avoids many of the technical limitations seen with surgery.
Recent evidence supports this explanation. The RHEIA trial (2024), the first randomized trial conducted exclusively in women with severe aortic stenosis, showed that TAVR was superior to SAVR for the composite of death, stroke, or rehospitalization at 1 year (8.9% vs 15.6%). Women are more prone to patient–prosthesis mismatch with surgery due to smaller annuli, and TAVR often provides better hemodynamics with shorter recovery and lower rates of atrial fibrillation.
With the wider adoption of TAVR after 2015, these advantages likely translated into a greater reduction in mortality among women at the population level, which is consistent with the steeper decline observed in our national data.
2. The increase in mortality among adults aged 55 to 64 stands in contrast to improvements in older groups. How do you interpret this finding, and do you think this suggests a gap in diagnosis or treatment for younger patients with aortic stenosis (AS)?
AS in this age group is more often related to bicuspid valve disease or accelerated calcification from metabolic risk factors. These patients may be underdiagnosed because AS is usually considered a disease of older adults. Early TAVR programs also prioritized elderly high-risk patients, which may have delayed intervention in younger individuals, suggesting a gap in early detection and referral.
3. Despite overall declines, nonmetro areas did not see significant improvement in mortality rates. Did your findings identify any barriers to TAVR access or cardiovascular care that might be driving these geographic disparities?
TAVR programs are concentrated in large metropolitan centers, so patients in rural areas may have limited access to specialty care, delayed diagnosis, and fewer referral pathways. Travel distance, socioeconomic factors, and lower availability of echocardiography or structural heart programs likely contributed to the lack of mortality improvement in nonmetro regions.
4. Your subgroup analysis shows improvements across all racial and ethnic groups, with the steepest declines among Asian/Pacific Islanders—what lessons can be drawn from these trends, and do they reflect differences in access, referral patterns, or underlying risk?
We observed mortality declines across all racial and ethnic groups, which is encouraging and suggests that the overall expansion of TAVR and structural heart programs has had broad impact. The steeper decline among Asian and Pacific Islander populations may reflect several factors, including higher concentration in metropolitan areas where TAVR programs are more available, as well as differences in health-care utilization patterns.
It is also possible that earlier adoption of guideline-directed evaluation and referral in certain health systems contributed to improved outcomes. However, these findings should be interpreted cautiously, as population size and regional distribution can influence national mortality trends.
Importantly, although all groups improved, disparities have not been eliminated. Continued efforts to ensure equitable access to valve intervention and specialty care remain essential.
5. How have these findings influenced your own clinical practice—particularly in terms of screening, referral timing, or patient selection for TAVR?
These findings reinforce the importance of early recognition and timely referral for patients with aortic stenosis. In our own practice, we are more attentive to subtle symptoms in older adults, particularly those who may attribute dyspnea or fatigue to aging rather than valve disease.
The data also highlight the need to consider intervention earlier in appropriate patients rather than waiting for advanced symptoms, especially now that TAVR has become a safe and effective option across a broad risk spectrum. In addition, we are more mindful of potential disparities in access, particularly for patients who live far from tertiary centers, and we try to facilitate referral to structural heart programs when severe disease is identified.
Overall, the study underscores that outcomes improve when patients are diagnosed early and evaluated in centers with access to contemporary therapies.
6. For clinicians who may not be as familiar with these national trends, what are the key takeaways from your study that should most immediately inform everyday care for patients with aortic stenosis?
The most important takeaway from this study is that mortality from aortic stenosis has begun to decline nationally in the era of TAVR, but the benefits have not been uniform across all populations.
Clinicians should maintain a high index of suspicion for aortic stenosis, especially in older adults with new symptoms such as exertional dyspnea, chest discomfort, or syncope. Early echocardiographic evaluation and timely referral to a valve center are critical, as intervention before advanced decompensation is associated with better outcomes.
The study also highlights the need to pay particular attention to groups that may be underdiagnosed or undertreated, including younger patients, those living in nonmetropolitan areas, and patients with limited access to specialty care.
Ultimately, the decline in mortality we observed reflects the success of modern valve therapies, but continued efforts in screening, referral, and equitable access are needed to ensure that all patients benefit from these advances.
Dr Rahman is a Cardiology Fellow at Lahey Hospital & Medical Center with a strong interest in population-level analyses evaluating real-world outcomes of contemporary cardiovascular therapies. His clinical and research focus includes multimodality cardiac imaging and structural heart interventions, including TAVR, transcatheter mitral and tricuspid therapies, and advanced CT/MRI imaging.
Acknowledgments: Dr Rahman would like to thank Dr. Saurabh Dani for his consistent guidance and mentorship, and Dr Sarju Ganatra for his valuable ideas and support throughout the project. He would also acknowledge the contributions of the amazing research team, especially Talha Shaukat, whose efforts in data analysis and dedication were instrumental to the completion of this work.
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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.
