Aortic stenosis (AS) is common, especially among the elderly. Left untreated, severe symptomatic AS is typically fatal. Surgical aortic valve replacement (SAVR) was the standard of care until transcatheter aortic valve replacement (TAVR) was shown to have lower mortality rates in patients at the highest surgical risk and was recommended for this group in the 2014 American Heart Association/American College of Cardiology (AHA/ACC) guidelines. In the 2017 AHA/ACC focused update, evidence of benefit and noninferiority extended the use of TAVR to intermediate-risk patients. More recent studies suggest potential benefit to low-risk patients, although no published guidelines yet recommend the use of TAVR for this population. An advantage of SAVR is a 30-year experience with valve durability, but SAVR may have higher rates of perioperative death and a slower return of quality of life. Although TAVR has less than 10-year experience with valve durability, it has lower or noninferior primary end points, such as mortality and stroke, and fewer periprocedural complications among anatomically permissive patients. Here, a cardiologist and a cardiothoracic surgeon debate the risks and benefits of TAVR versus SAVR for a patient with severe symptomatic AS who is at low risk for surgical death.
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Author, Article, and Disclosure Information
Eileen E. Reynolds,
Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.E.R., H.L.)
Lahey Hospital & Medical Center, Burlington, Massachusetts (S.J.B.)
Brigham and Women's Hospital, Boston, Massachusetts (T.K.).
Note Added in Proof: After the conference and manuscript were finalized, AHA/ACC published a new comprehensive guideline on valvular heart disease, including a section on management of AS (38). It recommends that for patients like Mr. M who are younger than 65 years, who have more than 20 years of life expectancy, who are at low surgical risk, and for whom bioprosthesis is appropriate, SAVR is preferred. This advice is consistent with the 2017 recommendations discussed above.
Acknowledgment: The authors thank the patient for sharing his story. The Beyond the Guidelines Editorial team thanks Dr. Mark Tuttle for his important contributions to this manuscript.
Grant Support: Beyond the Guidelines receives no external support.
Disclosures: Dr. Baron reports a grant from Edwards Lifesciences, consulting fees from Boston Scientific and Edwards Lifesciences, an honorarium from Boston Scientific, and participation on an advisory board for Boston Scientific. Dr. Kaneko reports consulting fees from Medtronic and consulting fees, an honorarium, payment for expert testimony, and support for attending meetings and/or travel from Edwards Lifesciences. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-0724.
Corresponding Author: Eileen E. Reynolds, MD, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215; e-mail, ereynold@bidmc.
Current Author Addresses: Drs. Reynolds and Libman: Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Dr. Baron: Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805.
Dr. Kaneko: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.
This article was published at Annals.org on 13 April 2021.