Emergency interventions for the treatment of decompensated aortic stenosis

> ‘Whosoever wishes to know about the world must learn about it in its particular details.’ —Heraklietos of Ephesos Transcatheter aortic valve implantation (TAVI) is endorsed in both the European and North American guidelines as the treatment of choice for symptomatic severe aortic stenosis in patients considered unsuitable for surgical aortic valve replacement.1 2 Neither of these documents places an upper limit of risk precluding TAVI, although patients should have an expected post-TAVI survival of at least 1 year. In patients with acutely decompensated severe aortic stenosis where the longer-term prognosis is poor or unclear, balloon aortic valvuloplasty (BAV) may be considered either as a palliative procedure or as a potential bridge to definitive therapy. The terms used to define this subset of patients are necessarily vague, as they attempt to encompass a diverse population and avoid being overly prescriptive. A number of case series and registry studies have been published describing clinical outcomes in very high-risk or acutely decompensated patients undergoing BAV as a bridge to valve replacement,3 TAVI in cardiogenic shock4 5 and emergency surgical aortic valve replacement.6 While informative, these data are limited by the bias inherent to non-randomised, observational studies and lack of an appropriate comparator. Thus, the optimal strategy for the management of severe aortic stenosis in patients with cardiogenic shock …