Transcatheter Aortic Valve Replacement Indications Should be Expanded to Lower-Risk and Younger Patients

Even in the late 1950s, patients suffering from significant aortic stenosis were confined to death owing to the absence of treatment option for the disease. The invention of extracorporeal circulation revolutionized cardiac surgery.1–3 Complex surgical intervention on the diseased heart became available, including replacement of the stenotic aortic valve.4 Especially in the early days of conventional aortic valve replacement (AVR), however, in-hospital mortality was up to 25% because of cardiac failure, bleeding or thromboembolic complications, infections, or arrhythmias.4–9 The design of the first mechanical heart valves left patients with peak gradients of ≥60 mm Hg. Applying the updated standardized end-point definitions for transcatheter aortic valve implantation (TAVI; Valve Academic Research Consortium [VARC] 2) definitions10 to this patient population would have resulted in a procedural success rate of 0%, and the US Food and Drug Administration probably would have never approved the devices. The world has changed considerably since then. Half a century later, conventional aortic valve surgery (AVR) can be considered a top turnaround story: nowadays, the operation is fast and easy and yields excellent outcomes in a broad patient population.11 This is the consequence of advances not only in technology but also in surgical experience gained in millions of patients with aortic stenosis. Today, minimally invasive techniques are applied that facilitate postoperative recovery, especially in elderly patients, and reduce the likelihood of wound infections.12 The flow properties of mechanical heart valves also improved remarkably, which led to less rigid need for anticoagulation and lower bleeding and thromboembolic complications.13 Stented and stentless bioprosthetic valves have been shown to be long-lasting, which reduces the need of reoperation in case of bioprosthetic valve failure.14,15 The hemodynamic results are excellent with low transvalvular gradients, regardless of whether mechanical or bioprosthetic …