Feature | From Last Resort to Early Intervention: How TAVR's Evolution Is Reshaping Care For Aortic Stenosis
For more than a decade, TAVR has transformed the treatment landscape for patients with severe aortic stenosis (AS). What started as a transformational new option for patients previously considered inoperable has evolved into a mainstream treatment option spanning the surgical-risk spectrum. Today, the field stands at another inflection point: the emergence of TAVR as a potential option for selected patients with asymptomatic severe AS.
Yet even as evidence and technology advance, an important challenge remains. Patients cannot benefit from modern therapies if they are not identified, evaluated and referred in a timely manner. A CardioSurve survey of ACC members who currently treat patients with AS suggests that closing gaps in diagnosis, management and referral may be just as important as the next procedural innovation.
The Expanding Reach of TAVR
TAVR first emerged on the scene in 2011, when the U.S. Food and Drug Administration (FDA) approved the therapy for patients with severe symptomatic AS who were not candidates for open-heart surgery. At the time, TAVR represented a lifeline for patients with no reasonable surgical alternative.
Subsequent FDA approvals continued to expand patient access. Between 2012 and 2016, TAVR was approved first for high-risk surgical patients and then those at intermediate-risk, reflecting growing confidence in procedural safety and effectiveness. In 2019, FDA approval was extended to appropriately selected patients at low surgical risk, establishing TAVR as a viable treatment option across virtually the full spectrum of patients with symptomatic severe AS.
Building the Evidence Base For the Next Era of TAVR
As TAVR continues to expand into new patient populations and clinical applications, robust real-world evidence remains essential to advancing patient care. Recent updates in the final NCD for TAVR released by CMS in September reflect the continued importance of rigorous data collection, evidence development and quality improvement in shaping the future of structural heart disease care.
The ACC and The Society of Thoracic Surgeons (STS) are actively engaging CMS to have the STS/ACC TVT Registry recognized as an approved study vehicle for asymptomatic AS patients, helping ensure the registry remains a comprehensive data resource for quality improvement, benchmarking, evidence generation, analytics and reporting.
In the meantime, for practical steps that clinicians can proceed with now, see below.
The Asymptomatic AS Debate Moves to the Forefront
Historically, asymptomatic severe AS has been managed through careful surveillance until symptoms developed or other guideline-directed triggers emerged.
That paradigm shifted significantly with the FDA's 2025 approval of the Edwards SAPIEN 3 platform for asymptomatic severe AS, marking the first U.S. approval of TAVR for patients without symptoms.
The approval was largely informed by the EARLY TAVR trial, which randomized 901 patients with asymptomatic severe AS to either early transfemoral TAVR or clinical surveillance. Over a median follow-up of 3.8 years, early intervention reduced the composite endpoint of death, stroke or unplanned cardiovascular hospitalization compared with surveillance. Much of that benefit was driven by reductions in unplanned cardiovascular hospitalizations.
For some clinicians, the trial provides evidence that waiting for symptom development may expose patients to avoidable risk. For others, important questions remain regarding optimal patient selection, lifetime valve management and durability considerations.
The CardioSurve survey captured this tension.
One respondent noted that, "Aortic stenosis remains underdiagnosed and undertreated, particularly among asymptomatic patients and those with multiple comorbidities. Future efforts should focus on improving longitudinal surveillance, standardized echocardiography reporting, risk stratification for earlier intervention, and automated guideline-based referral pathways integrated into the electronic medical record."
Others urged caution. One cardiologist wrote, "I feel that the bar to TAVR is too low and many patients are being referred too early for low risk 'severe AS' and being offered the wrong procedure."
These differing perspectives reflect a broader reality across cardiovascular medicine. The question is increasingly no longer whether asymptomatic severe AS should ever be treated, but rather which patients are most likely to benefit and when.
In parallel, the FDA approved valve-in-valve indications for selected patients with failed surgical bioprosthetic valves, creating less invasive treatment pathways for patients facing repeat valve interventions.
Today, TAVR has become an integral component of contemporary valve management, with decision-making increasingly focused on age, anatomy, procedural risk, valve durability, coronary access and lifetime valve strategy. TAVR also solidified the role of the Heart Team approach to optimize patient selection and outcomes.
Why Patients Are Still Being Missed
Despite these advances, severe AS often remains underrecognized until later stages of disease. Symptoms like fatigue, exertional dyspnea, dizziness or declining exercise tolerance can be subtle and attributed to aging or other comorbid conditions. In addition, murmur findings may be variable and functional decline often occurs gradually. Even after an echocardiogram identifies concerning findings, referrals may not always occur promptly.
Results from the CardioSurve survey underscore these challenges. While the vast majority of cardiologists (81%) recognized the value of earlier disease detection in improving patient outcomes, nearly half identified unclear symptoms or symptoms attributed to other causes as a major obstacle to diagnosis.
Risk assessment is another area of uncertainty, with 61% of survey respondents indicating significant uncertainty regarding which patients with moderate AS are at highest risk. More than 40% cited the need for additional testing to confirm disease severity.
Additionally, 54% of cardiologists felt the absence of objective guidance regarding intervention timing in asymptomatic severe AS creates management challenges.
Building Better Referral Pathways
These findings underscore a growing reality in valve care: identifying severe disease is no longer the only challenge. As the timing of intervention becomes increasingly complex, a consistent theme from the CardioSurve survey is the need to improve how patients move through the care continuum, from diagnosis and surveillance to referral and treatment.
More than half of cardiologists reported at least one challenge when making referrals for severe AS, with discordant or incomplete echocardiographic findings (36%) and competing comorbidities (34%) cited most frequently.
One respondent observed that "ambiguity and lack of clarity in reporting, as well as inter-reporter variability, are major concerns and may lead to delayed decisions, especially for asymptomatic patients."
Nearly three-fourths of those surveyed felt that standardized prescriptive echocardiography reporting could help reduce ambiguity and improve downstream care.
Other enhancements, including integrated EHR notifications directed specifically to the ordering clinician and automated referral pathways may also be ways to potentially improve accountability and/or further streamline care, particularly in community practices where competing clinical priorities can delay follow-up.
Among those using or planning to use automated recommendations, the leading benefits included earlier identification of patients who might benefit from intervention (68%) and improved physician workflow efficiency (56%). For example, 30% of survey respondents expressed support for embedded clinical recommendations within finalized echo reports.
However, significant challenges to broad adoption remain, with alert fatigue the most dominant concern, followed closely by EHR integration and overly broad referral recommendations.
These findings suggest that clinicians want support, but not noise. They want smarter alerts: recommendations that are timely, targeted, actionable and directly connected to evidence-based care pathways.
Resources
- Read the April 2022 issue of Cardiology celebrating the 20th anniversary of TAVR.
- Bookmark ACC.org/Guidelines for ACC's library of clinical guidance, including guidelines, expert consensus documents, concise clinical guidance, training statements and more.
- Access CardioSmart patient resources on aortic stenosis, including decision guides and infographics.
- Explore ACC's live coverage from TCT 2026 in San Diego at ACC.org/TCT2026 and explore JACC Journals simultaneous publications at JACC.org.
Looking Ahead
The evolution of TAVR in just over a decade has been remarkable. Now, the field is poised for the next chapter involving asymptomatic disease. FDA approval has expanded the conversation. The new Centers for Medicare and Medicaid Services (CMS) National Coverage Determination (NCD) has clarified current coverage realities. And clinicians are actively debating how best to balance earlier intervention against durability concerns and lifetime valve management strategies.
What appears less controversial is the need to identify severe AS earlier and create more reliable referral pathways. The CardioSurve findings suggest broad consensus that better surveillance, clearer echo reporting, improved workflow tools and stronger Heart Team coordination can enhance patient care.
As one survey respondent summarized, "Better coordination among cardiologists, primary care clinicians and multidisciplinary Heart Valve Teams, together with patient education and shared decision-making tools, has the potential to improve timely intervention and clinical outcomes."
As TAVR continues to evolve, that may ultimately prove to be the next major frontier in aortic stenosis care: not simply advancing the procedure itself – but ensuring that every appropriate patient reaches treatment at the right time.
How to Proceed Now: Practical Steps For Clinicians
Even as evidence, guidelines and coverage policies continue to evolve, clinicians can take practical steps now to improve disease awareness and reduce missed opportunities for timely care. The goal is to create more reliable systems for recognizing risk, reassessing disease progression and engaging the Heart Team when clinical uncertainty exists.
Clinicians can consider the following actions:
Listen for subtle symptom changes. Ask specifically about fatigue, reduced walking distance, slower pace, exertional shortness of breath, dizziness or avoidance of activities that patients may not describe as "symptoms."
Do not rely on a single clinical clue. A murmur, patient report or one echocardiogram may not fully capture disease trajectory. When findings are discordant or symptoms are unclear, consider repeat assessment or additional testing.
Track progression over time. Compare current and prior echocardiograms, symptoms and functional status to identify patients whose disease may be advancing, even if they have not reached a clear treatment threshold.
Use echocardiography reports as decision tools, not just diagnostic records. Clear documentation of AS severity, valve gradients, valve area, flow status and recommended follow-up timing can help reduce ambiguity for the ordering clinician.
Build referral triggers into routine workflow. Practices may benefit from agreed-upon criteria for when severe AS, rapid progression, discordant findings or uncertain symptom status should prompt Heart Team discussion.
Engage the Heart Team early when uncertainty exists. Referral does not automatically mean intervention. It can help clarify diagnosis, assess anatomy, evaluate procedural risk and discuss a lifetime valve-management strategy.
Educate patients before symptoms become obvious. Patients with moderate or severe AS should understand what symptoms to watch for, why follow-up matters and when to contact their care team.
Moderate AS With Symptoms vs. Asymptomatic Severe AS
Moderate AS with symptoms and asymptomatic severe AS require different clinical questions. In symptomatic moderate AS, the priority is to confirm stenosis severity and look for other causes of dyspnea or functional limitation. In asymptomatic severe AS, the valve disease is already severe, so the decision focuses on whether early intervention may improve outcomes before symptoms develop. Current guideline frameworks still inform which patients warrant intervention vs. surveillance.
| Clinical Question | Moderate AS With Symptoms | Asymptomatic Severe AS |
| Primary issue | Symptoms are present, but AS has not met severe criteria. | AS is severe, but the patient does not report symptoms. |
| Main clinical task | Reassess AS severity, confirm symptoms and evaluate alternate contributors such as HFpEF, lung disease, anemia, deconditioning, coronary disease or other valve disease. | Confirm true absence of symptoms, often with exercise testing, and assess high-risk features that may favor early intervention. |
| TAVR status | Not routinely indicated solely for moderate AS outside progression to severe AS, concomitant cardiac surgery or clinical trial consideration. | An emerging option for selected patients after EARLY TAVR and 2025 FDA approval activity, but not a default strategy for all asymptomatic patients. |
| Practical framing | A diagnostic and surveillance challenge. | An early-intervention and lifetime valve-strategy decision. |
Practical distinction: Moderate symptomatic AS is usually a diagnostic and surveillance challenge; asymptomatic severe AS is increasingly an early-intervention decision. For asymptomatic severe AS, the Heart Team should verify symptom status, AS severity, anatomy, procedural risk and lifetime valve strategy before recommending TAVR.
Survey Details
To assess cardiologists' perceptions of the diagnosis and management of aortic stenosis. A survey was sent to 521 U.S.-based ACC CardioSurve panelists. From July 10 to Aug. 13, 156 panelists responded to the screening question for treating AS, for a 30% response rate; 146 met the inclusion criterion of currently treating patients with AS.
New Free ACC Online Course: Transforming AS Care
Improve your approach to identifying and evaluating aortic stenosis (AS) with ACC's new online course, Transforming AS Care: An Optimal Approach to Screening & Diagnosis. Explore the latest evidence surrounding moderate and severe AS, guideline-informed approaches to assessing disease severity, and factors that can contribute to underdiagnosis and delayed treatment.
Learn on the go with the podcast episode "What Clinicians May Be Missing: Overcoming Barriers to AS Diagnosis," and two Quick Tips videos: "AS: The Murmur Matters" and "Red Flags For Underdiagnosis." Plus, be on the lookout for more podcast episodes, videos, interactive case challenges, quizzes and more launching soon! Start learning.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease
Keywords: Cardiology Magazine, ACC Publications, CM-Nov-2026, Transcatheter Aortic Valve Replacement, Aortic Valve Stenosis
