TAVI the frontier of interventional cardiology 40 years after the first ballon angioplasty

Forty years ago on 16 September 1977, Andreas R. Grüntzig performed his seminal procedure that led to the development of interventional cardiology as a novel discipline of cardiology.1 Ever since, the spectrum of catheter-based interventions has been expanded from coronary2–4 to valvular heart disease. Indeed, valvular heart disease has enjoyed an impressive revival of interest recently, thanks to the introduction of transarterial valve implantation or TAVI5 and catheter-based interventions at the mitral6,7 and, most recently, the tricuspid valve.8 This has also revitalized the discussion on the use of surgical valves. Mechanical valves are still frequently used for surgical aortic valve replacement, but continue to be associated with bleeding risks,9 because of the requirement for anticoagulation with vitamin K antagonists, while bioprosthetic valves do not require that, but are at risk of structural valve deterioration requiring re-operation.10 The decision as to what valve to use in patients undergoing surgery for aortic stenosis is extensively discussed in a review entitled ‘Mechanicalvs.bioprosthetic aortic valve replacement’ by Stuart J. Head and colleagues from the Erasmus University Medical Center in Rotterdam, The Netherlands.11 These risk and benefit considerations of mechanical and bioprosthetic valves has led to American and European guidelines12 on valvular heart disease recommending the use of mechanical prostheses in patients younger than 60 years of age. Despite these recommendations, the use of bioprosthetic valves has increased in all age groups. A systematic review applying propensity matching or multivariable analysis to compare the usage of mechanical vs. bioprosthetic valves found either similar outcomes between the two types of valves or favourable outcomes with mechanical prostheses, particularly in younger patients. Indeed, current evidence does not support lowering the age threshold for implanting a bioprosthesis. Heart Teams and patients should be cautious in pursuing more bioprosthetic valve use until its benefit is clearly proven in middle-aged patients.