Severe aortic valve stenosis in low-risk elderly patients; which is the role of surgery?

Cite this article as: Baikoussis NG, Alexopoulou-Prounia L, Limperiadis D. Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery. Interdiscip CardioVasc Thorac Surg 2023; doi:10.1093/icvts/ivac109. Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery Nikolaos G. Baikoussis , Loukia Alexopoulou-Prounia LETTER TO THE EDITOR LETTER TO THE EDITOR Interdisciplinary CardioVascular and Thoracic Surgery 2023, 36(1), ivac109 https://doi.org/10.1093/icvts/ivac109 * and Dimitrios Limperiadis Cardiac Surgery Department, Ippokrateio General Hospital of Athens, Athens, Greece Received 25 January 2022; accepted 13 January 2023 Keywords: Aortic valve stenosis • Aortic valve replacement • Transcatheter valve implantation • Heart valve surgery We read with great interest the paper published by Magro and Sousa-Uva [1] on the superior technique in terms of reported composite outcomes and survival, among transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement for low-risk patients aged >70–75 years with severe aortic stenosis. It is currently unclear if older age should be a criterion for the choice between TAVR and surgical aortic valve replacement in otherwise low-risk patients. As the authors acknowledge, ‘the only low-risk randomized control trial to date regarding an elderly population (NOTION) [2, 3] did not show a statistically significant difference between the 2 approaches regarding the composite end-point of death, stroke or myocardial infarction’, while in other studies [4] subgroup analysis of the elderly patients (>75 years) also concluded in similar results for both techniques regarding death or stroke at 2 years follow-up. As the authors acknowledge, risk scores and other procedural risk factors associated or not with age comprise the cornerstone of approach selection. We therefore agree with the decision of the authors to review the current literature to propose the best management option for your patients and also elucidate future heart-team discussions. While we support the conclusions, we would like to point out that the main limitation of all studies included in the review is the fact that they were not randomized, apart from one, and therefore subject to a significant source of bias. What is more, as the authors acknowledge, since PARTNER 2 trial’s 5-year results showed a significantly higher rate of mild paravalvular aortic regurgitation (33.3% vs 6.3%), frequency of hospitalizations (33.3% vs 25.2%) and aortic valve reinterventions (3.2% vs 0.8%) [1], primary composite end points and the limited follow-up period of the existing studies may not be enough to justify the age as an independent decision-making factor. We agree with the authors that the current literature does not show any significant superiority in either technique; however, we believe that large RCT will solve the question as to which procedure is superior in this specific population, especially since the majority of the current studies, the group sample for 5-year follow-up outcomes is undersized, and the subgroup of patients older than 74 years old is even more undersized. We also like to notice from our experience the importance of the type of valves used for TAVR as well as the interventional cardiologist’s skill and familiarization with each valve. Both the CoreValveV Revalving system (Medtronic, Inc., Minneapolis, MN, USA) and the Edwards Sapien system (Edwards Lifesciences Corporation, Irvine, CA, USA) have proved their effectiveness in the recent outcomes of the CoreValve US Pivotal and Partner trials, respectively. Additional RCTs are required not only to inform practice but also to grade the quality of the evidence and to update our guidelines. R REFERENCES [1] [2] [3] [4] Magro PL, Sousa-Uva M. In low-risk patients aged >70–75 with severe aortic stenosis, is transcatheter superior to surgical aortic valve replacement in terms of reported cardiovascular composite outcomes and survival? Interact CardioVasc Thorac Surg 2022;34:40–4. Thyregod HG, Steinbrüchel DA, Ihlemann N, Nissen H, Kjeldsen BJ, Petursson P et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis: 1-year results from the AllComers NOTION Randomized Clinical Trial. J Am Coll Cardiol 2015;65: 2184–94. Thyregod HGH, Ihlemann N, Jørgensen TH, Nissen H, Kjeldsen BJ, Petursson P et al. Five-year clinical and echocardiographic outcomes from the Nordic Aortic Valve Intervention (NOTION) randomized clinical trial in lower surgical risk patients. Circulation 2019;139:2714–23. Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O’Hair D et al.; Evolut Low Risk Trial Investigators. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients. N Engl J Med 2019;380:1706–15. C The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. V This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/icvts/article/36/1/ivac109/6988034 by guest on 18 January 2023 * Corresponding author. Cardiac Surgery Department, Ippokrateio General Hospital of Athens, 114 Vasilissis Sofias Avenue, Athens 11527, Greece. Tel: +30-6986680123; e-mail: loukia_ale07@yahoo.gr (L. Alexopoulou-Prounia).