Aortic valve replacement vs. transcatheter aortic valve implantation: Patient selection.

Transcatheter aortic valve implantation is the treatment of choice for symptomatic aortic stenosis in the unacceptably high-risk or inoperable patients, and is a reasonable option for high-risk patients in general. Currently, there is no evidence suggesting that TAVI provides more favorable clinical outcomes than those of conventional AVR in moderate-risk patients. Although the results of the early TAVI experience are promising, longer-term follow-up is necessary before the procedure can be extended to lower risk or younger patients. With current devices and technologies, TAVI is associated with a high incidence of paravalvular leaks, which has been shown to have a negative impact on long-term outcomes. Before this issue is addressed, it is inappropriate to extend/offer TAVI to low-risk or young patients with moderate operative risk. Evidence-based guidelines need to be developed to ensure all patients with aortic stenosis receive optimal therapy. As with percutaneous intervention and coronary artery bypass grafting for coronary artery disease, conventional AVR and TAVI will likely be offered to different groups of patients. For the foreseeable future conventional AVR will be the treatment of the choice in low-risk or younger (<60-65 years) patients, while TAVI will be offered to the moderate- to high-risk and relatively elderly patients.