The Ethical Challenge of Waiting Lists for TAVR

During the last decade, transcatheter aortic valve replacement (TAVR) has become a viable option for patients with moderate to severe aortic valve stenosis who are either not candidates for open-heart surgery or prefer a less invasive method of valve replacement. When first introduced, TAVR was only a rescue procedure for patients with severe aortic stenosis and not deemed fit to undergo open-heart surgery under general anaesthesia. However, since then, many clinical trials have been conducted on TAVR and both short and long term results are comparable to open-heart surgery. 

Over the years, TAVR technology and equipment have also become more refined and most cases are performed via transfemoral access. But the cost of surgery still remains high. The procedure entails the participation of a cardiologist, an anaesthesiologist, and staff from the cardiac catheterisation laboratory, The operating room must be available on standby in case there is a complication, and the cost of disposable instruments significantly adds to the overall cost of surgery compared to open heart surgery. 

Recently the FDA announced that TAVR should also be an option for low risk patients who have severe aortic stenosis. TAVR is not only associated with fewer complications but is less morbid than the open procedure. Unfortunately, it appears that because of the cost of surgery, the TAVR is not being offered to younger people with severe aortic stenosis.

There is a concern that this may lead to a growing waiting list of patients. Anecdotal reports from Canada and Spain already indicate that there are a number of younger patients waiting for the procedure. The question is: ‘is it ethical to place young patients on a waiting list, when there is already a procedure available to treat their disorder?’

Ethicists from Canada argue that while surgeons may ultimately decide on the criteria for aortic valve surgery, TAVR should be offered to younger patients with the same criteria as older patients, if it is available. Also being argued at the same time is that the cost of TAVR is much higher than open heart surgery and as such may be a deciding factor as to why younger patients may not be selected. There is also a suggestion that the ultimate decision on surgery should not only involve the surgeon but also the cardiologist and the patient.

At the moment, older and sicker patients with severe aortic stenosis are managed with TAVR but younger patients are being placed on a waiting list. There is no deep philosophical reason as to why TAVR is not being recommended to younger patients- the answer it is that is an expensive procedure. As the waiting list of patients needing TAVR grows, ultimately someone will have to come up with a solution.