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Who should get surgical aortic valve replacement in the era of transcatheter aortic valve replacement?-a surgeon's perspective.

Over the last decade, transcatheter aortic valve replacement (TAVR) has become a widely adopted technology (1). Two landmark trials established TAVR as a viable treatment option for non-operative candidates and those with extreme surgical risk, based on the Society of Thoracic Surgery Predicted Risk of Mortality (STS PROM) model for isolated AVR and as determined by the heart team (2-4). Concurrently, trials randomizing high-risk patients to TAVR or surgical aortic valve replacement (SAVR) demonstrated non-inferiority between the two (PARTNER 1A) or, in the case of the CoreValve High-Risk Trial, superiority of TAVR for all-cause mortality (4,5). This led to the first FDA approval of TAVR in the United States. Subsequent intermediate-risk trials showed TAVR to be non-inferior in terms of all-cause mortality or disabling stroke (6,7). These studies provided the first evidence that TAVR was noninferior to SAVR in terms of mortality, with comparable or lower stroke rate, less acute kidney injury, transfusions, atrial fibrillation, time in the ICU or hospital, and faster recovery of function and quality of life. However, this occurred at the cost of more vascular complications, higher permanent pacemaker implantation (PPI) and incidence of paravalvular leak (PVL). With similar mortality but differences with respect to other important outcomes, the intermediate-risk trials started to shed light on differences between the two treatment modalities, making the STS PROM but one criterion for selecting the appropriate AVR strategy. Finally, in 2019, the 1-year data from two trials comparing TAVR against SAVR in patients with a low risk of 30-day mortality for isolated SAVR, were presented and resulted in approval of TAVR by the FDA for the treatment or severe, symptomatic aortic stenosis (ssAS) in all STS PROM risk categories (8,9). With this, the surgical risk profile has been removed permanently as the main deciding factor in justifying TAVR. In fact, these trials provide compelling evidence for the use of TAVR in the respective study sample. It is an understanding of what comprises the population tested, especially in low-risk patients, that is critical when applying these results to clinical practice.