How TAVI is transforming care in Aotearoa

For decades, open-heart surgery was the standard treatment for patients with severe aortic stenosis — a life-threatening narrowing of the heart’s aortic valve caused by wear and tear.

As the valve stiffens, it becomes harder for the heart to pump blood around the body. Left untreated, the condition can lead to heart failure, chest pains, loss of consciousness, or sudden death.

Today, a much less invasive treatment is transforming care.

Transcatheter Aortic Valve Implantation (TAVI) allows doctors to replace the diseased valve through a small incision, often through an artery in the groin, without opening the chest.

Many patients can undergo the procedure under conscious sedation, return home the next day, and recover far more quickly than after traditional open-heart surgery.

International guidelines increasingly support TAVI as a preferred treatment for many patients who meet the criteria.

But access to the procedure — and to the diagnostic tests that identify patients who need it — is not always consistent across Aotearoa New Zealand.

Part of the challenge is workforce capacity.

While New Zealand’s population has grown by around 17% since 2013, the cardiac workforce has not kept pace. In fact, in some areas it has declined.

Today, there are only half as many cardiac sonographers as there were in 2013, despite growing demand.

These specialists perform echocardiograms — ultrasound scans that detect conditions such as aortic stenosis before they become emergencies.

At the same time, New Zealand has only about one-third of the cardiologists it needs.

Fewer specialists can mean longer waits for diagnosis, assessment, and treatment, potentially delaying access to procedures such as TAVI.

Dr Sanjeevan Pasupati, one of New Zealand’s leading interventional cardiologists specialising in structural heart disease, was a pioneer of TAVI in Aotearoa.

“In Waikato, we're doing well. We perform about 200 TAVI procedures each year, but that’s not enough — we need to do more.

“There’s still more to be done for the rest of New Zealand — some regions haven’t caught up yet.”

For suitable patients, the difference between TAVI and open-heart surgery can be significant.

Because the procedure is far less invasive, recovery is usually quicker and complications are often fewer.

Many patients return home the following day and resume everyday activities sooner than they could after major surgery.

In recent years, the group of patients who may benefit from TAVI has expanded.

International guidelines increasingly support the procedure for a broader range of patients, including some aged between 65 and 80.

New national guidelines are expected to bring New Zealand practice more closely into line with these recommendations.

However, introducing new treatments into a health system is rarely just about technology or clinical expertise.

“The hardest part is getting patients worked up and ready,” Dr Pasupati says.

“The investigations need to be done before and after TAVI procedures.”

Preparing patients for TAVI requires detailed imaging, including CT scans and echocardiograms.

Limited access to these services in some regions can slow the process of identifying suitable patients and preparing them for treatment. Ongoing imaging is also needed after the procedure to monitor the replacement valve.

For some patients, TAVI offers a second chance.

Susan Bennett experienced this first-hand.

After being diagnosed with aortic stenosis, she initially underwent open-heart surgery to replace her valve.

However, the valve implanted during surgery turned out to be too small for her body, leaving her struggling to recover.

“I couldn’t get out of bed. I didn’t care about showering or cleaning my teeth, and that’s not like me,” she says.

Doctors later determined that TAVI might offer another option.

At the time, Susan was younger than the typical age threshold for the procedure, but her medical team advocated for her to receive it following a suboptimal outcome from cardiac surgery.

“It was just so much easier on my body,” she says.

“My family couldn’t believe it when they saw me sitting up after TAVI — the difference was incredible."

“My doctors virtually saved my life because they couldn't redo me with open heart,” she says.

“There was no other way to save me other than TAVI.”

Nearly a decade later, Susan continues to live well with her implanted valve.

Although TAVI is funded through the public health system, access can vary depending on where patients live.

Because the procedure is not mandated nationally, individual hospitals determine how many procedures they can provide.

“We’ve come a long way, but there is still more to do to make access equitable across the country,” Dr Pasupati says.

Capacity constraints play a role. In some regions, limited catheter laboratory availability and restricted access to CT imaging can delay assessment and treatment.

Growing demand for echocardiography also places pressure on a workforce that has already declined.

While the valve used in TAVI is more expensive than a surgical valve, the overall periprocedural cost is much cheaper, and focusing only on the valve cost misses the broader picture, Dr Pasupati says.

“When you look at the total cost of care, TAVI is cheaper,” he says.

TAVI represents a major advance in the treatment of severe aortic stenosis, offering many patients a safer and less invasive alternative to open-heart surgery.

But ensuring that people across New Zealand can benefit from it will require support from the top down, Dr Pasupati says.

“Without addressing the ongoing pressures facing cardiac care in New Zealand, some patients will continue to face significant delays.”