Too Early to Tell
The Complexity of Decision Making for Aortic Stenosis Patients at Low Surgical Risk
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The report from De Sciscio et al1 in this issue of Circulation: Cardiovascular Quality and Outcomes, suggestively titled “Quantifying the shift toward transcatheter aortic valve replacement in low-risk patients...,” illustrates the great interest of many stakeholders to predict the ultimate role of transcatheter aortic valve replacement (TAVR) in the treatment of severe aortic stenosis (AS). TAVR was commercially approved for patients with high to prohibitive surgical risk in 2011 and expanded to intermediate-risk patients in August of 2016. Now, ≈30% of TAVR centers in the United States are participating in 1 of 2 randomized trials comparing TAVR to surgery in low-risk patients.2,3 Our knowledge of the implications of TAVR in low-risk patients is limited, but apt to change in coming years with the results of ongoing trials.
See Article by De Sciscio et al
Not surprisingly, there is an inevitable desire by policy makers, industry, the medical community, and others to take our past experience with TAVR in high-risk patients and apply it to lower risk populations to understand how this disruptive technology will affect surgical practice. In this context, De Sciscio et al1 sought to summarize available studies examining the prevalence of AS, and rates of progression to valve replacement, to define who may be eligible for surgical aortic valve replacement (SAVR), TAVR, or both in the coming years. Although this is a worthwhile endeavor, it is in the concept of eligibility where the predictions may be severely limited in defining how many patients there will be to shift from a surgical to a transcatheter approach. …