If you can look into the seeds of time and say which grain will grow and which will not speak then to me. Macbeth; William Shakespeare.
Predictions of the role of transcatheter aortic valve replacement (TAVR) in moderate-risk patients is fraught with potential pitfalls. The matrix of outcomes is interlinked and changes in one cell may have consequences beyond currently observable measures. For example, the Congressional Budget Office (CBO) options for cost reductions (‘caps on spending’) being presented to lawmakers, reads like rationing for healthcare and new technologies. Moreover, neither Europe, Canada nor Scandinavia are immune and if anything, many are more restricted, such as Belgium. It is thus incumbent upon us physicians to consider options both locally and more globally for the management of our patients.
The previous randomised study of the Placement of Aortic Transcatheter Valves (PARTNER) trial showed that TAVR was superior to medical treatment and that TAVR was equivalent to open aortic valve replacement (AVR) for mortality, although the stroke or transient ischaemic attack (TIA) rate was three times higher. Long-term data are, however, not available for valve durability, particularly in younger patients with longer expected survival. Open surgical treatment is established, highly successful and safe treatment for aortic valve stenosis that both relieves symptoms and very markedly extends survival. The seed of TAVR has been planted, is growing, and only time will tell how TAVR compares with AVR. Thus the use of TAVR in lower risk, and hence younger patients, needs to address safety and durability and also the trade-off of less invasive procedure for greater risk of stroke.