The Placement of Aortic Transcatheter Valve (PARTNER) Trial

The Placement of Aortic Transcatheter Valves (PARTNER) trial randomized inoperable patients with severe symptomatic aortic stenosis (AS) to medical therapy versus transcatheter aortic valve replacement (TAVR) in 1 arm (PARTNER B) and high-surgical-risk AS patients to surgical aortic valve replacement (SAVR) versus TAVR in the other arm (PARTNER A).1,2 TAVR was far superior to medical therapy in PARTNER B, and TAVR had a mortality similar to that of SAVR in PARTNER A.The impact of PARTNER is hard to overestimate. It was an elegant randomized trial in an area of cardiology noted for its dearth of such trials.3 It reiterated the gravity of symptomatic AS and demonstrated the power of a previously unavailable therapy for AS, yet it also expressed caution in the application of this exciting new therapy.The very fact that PARTNER was a randomized, controlled trial is by itself noteworthy. The American College of Cardiology/American Heart Association guidelines for the management of patients with valvular heart disease are unique among all of the American College of Cardiology/American Heart Association guidelines in that only a single recommendation (balloon mitral valvotomy for mitral stenosis) was based on a Level of Evidence A (0.3% of the total). Seventy-five percent of the recommendations were supported by only a Level of Evidence C (consensus of opinion). Although a half-million patients with coronary disease and/or heart failure have been enrolled in randomized controlled trials, only a hundredth of that number have been enrolled in randomized controlled trials aimed at therapy for valvular heart disease. Thus, PARTNER by itself increases the number of randomized valve patients by ≈17%. PARTNER vitiates many of the reasons given to explain why until now so few patients have been randomized—too hard to recruit, high variability in therapeutic techniques, too expensive, etc—by showing that such …