Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: https://www.bmj.com/company/legal-information/
Re: Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline
We read the Rapid Recommendation by Vandvik et al  published 28th September 2016 with interest. In this article the authors recommend transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement (SAVR) in all patients with symptomatic aortic stenosis, 75 years and older, irrespective of surgical risk. There is no evidence to support this recommendation.
Surgical aortic valve replacement remains the gold standard treatment for patients with symptomatic aortic stenosis. There is good evidence to support excellent long term outcomes. Two recent publications in BMJ have demonstrated excellent long term outcomes of surgical aortic valve replacement. A retrospective study in the UK of patients undergoing SAVR with a mean age of 75 years showed a hospital mortality of only 1.5% and a median survival of 11 years . A large meta analysis by the same authors as this recommendation, concluded that SAVR using a bioprosthetic valve conveys a survival close to the general population of the same age .
The only randomised trial of TAVI versus SAVR in low risk patients was the NOTION trial which concluded equivalence at one year in terms of survival . The PARTNER 2A trial was designed to compare TAVI and SAVR in intermediate risk patients . In fact, the mean age of these patients was 81 years, 93.3% had an STS score of 4 or more, half had previous cardiac surgery, a third had COPD and half were considered to be frail. These characteristics would be considered high risk by many cardiac surgeons. Even in these patients there was no survival benefit of TAVI over SAVR.
Both of these studies look at only short term outcomes up to two years. However, we must be considering long term outcomes for a 75 year old requiring aortic valve intervention.
Both European and American guidelines only recommend TAVI in patients at high surgical risk [6.7]. The UK TAVI trial is currently recruiting intermediate risk patients and therefore such patients should only be treated as part of a clinical trial.
In conclusion, we do not feel that this Rapid Recommendation accurately reflects current best evidence. Surgical aortic valve replacement should have a strong recommendation in patients at low and intermediate risk in all age groups. Those at high surgical risk should have equivalent recommendation. All patients should be discussed by an experienced Heart Team and be given accurate information regarding current best evidence.
Martin T Yates, Rakesh Uppal, Neil Roberts
Department of Cardiothoracic Surgery, Barts Heart Centre, London
1. Vandvik PO, Otto CO, Siemieniuk RA, Bagur R, Guyatt GH, Lytvyn L et al. Transcatheter or surgical aortic valve replacement for patient with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline. BMJ 2016; 354: i5085
2. Sharabiani MT, Fiorentino F, Angelini GD, Patel NN. Long term survival after surgical aortic valve replacement among patient over 65 years of age. Open Heart 2016; 3(1): 1-8
3. Foroutan F, Guyatt GH, O’Brien KO, Bain E, Stein M, Bhagra S et al. Prognosis after surgical replacement with a bioprosthetic aortic valve with severe symptomatic aortic stenosis: systemic review of observational studies. BMJ 2016; 354: i5065
4. Thyregod HGH, Steinbruchel DA, Ihlemann K, Nissen H, Kjeldsen BJ, Petursson P et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stensosis. JACC 2015; 65(20): 2184-2194
5. Leon MB, Smith CR, Mack MJ, Makkar RR, Svensson LG, Kodali SK et al. Transcatheter or Surgical Aortic Valve Replacement in Intermediate Risk Patients. NEJM 2016; 374(17): 1609-1620
6. Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Baron-Esquivias, Baumbartner H et al. Guidelines on the management of valvular heart disease. European Heart Journal 2012; 33: 2451-2496
7. Nishimura R, Otto CM, Bonow RO, Carabello BA, Erwin III JP, Guyton RA et al. 2014 AHA/ACC Guidelines for the Management of Patients with Valvular Heart Disease. J Am Coll Cardiol 2014; 63(22): e57-e185