Reply to Nezic et al.

Reply to Nezic et al. Guidelines, Valve disease, Valve surgery, Percutaneous valve intervention, Aortic regurgitation, Aortic stenosis, Mitral regurgitation, Mitral stenosis, Tricuspid regurgitation, Tricuspid stenosis, Prosthetic heart valves The European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines on valvular heart disease [1] provide guidance for the diagnostic workup for patients with aortic stenosis and give recommendations for appropriate treatment strategies. Since the last version of the guideline in 2012, a huge amount of new evidence has been generated with regard to the risks and benefits of surgical aortic valve replacement and interventional transcatheter aortic valve implantation (TAVI) treatment for severe aortic stenosis. Although for inoperable patients and patients with high surgical risk TAVI has evolved as the therapy of choice if no anatomical or technical criteria render a transcatheter approach impossible, for intermediate risk patients, the available studies demonstrate equipoise with regard to the primary outcome. It is made very clear in the guidelines that the decision to perform surgical aortic valve replacement or TAVI cannot be based on a single number such as age or the EuroSCORE alone. Rather, the decision relies on an iterative process that takes all the factors into account that have a possible impact on the outcomes. Hence, the joint task force of ESC and EACTS tried to define an algorithm to rationalize the use of either therapy in this particular patient cohort. In the centre of this algorithm stands the local heart team that has to address the complex interaction of individual risk factors, comorbidities, technical feasibility and expected early and long-term outcomes that are specific for each procedure. In most trials, the lower cut-off for ‘intermediate risk’ was chosen to be 4% by the Society of Thoracic Surgeons (STS) or EuroSCORE II. Patients with risk scores lower than this cut-off were largely excluded. The task force was totally aware of the fact that this definition represents an arbitrary cut-off that is not supported by a large body of literature. In the absence of a better stratification model, it was, however, decided to follow these lines as evidence has accumulated around them. This does by no means imply that every patient in the intermediate risk group with the EuroSCORE II of 4% or higher should be treated with TAVI by default. This is also clearly stated in Table 7, which is designed to provide guidance for the decision-making process within the Heart Team. The authors refer to their own results in a group of patients with a mean EuroSCORE II of 1.93%, representing a low-risk group of patients [2]. For this cohort, the guidelines clearly recommend surgery. The authors confirm this recommendation by their excellent surgical results. The observed mortality of 1.43% leads to a favourable O:E ratio of 0.74 and, hence, proves that guideline adherence provides excellent outcomes. REFERENCES 1 Falk V , Baumgartner H , Bax J , DeBonis M , Hamm C , Holm PJ et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease . Eur J Cardiothorac Surg 2017 ; 52 : 616 – 64 . Google Scholar CrossRef Search ADS PubMed 2 Nezic DG , Petrovic I , Micovic S. How have task force members determined the threshold value of EuroSCORE II for an increased surgical risk in patients undergoing aortic valve interventions? Eur J Cardiothorac Surg 2018 ; doi:10.1093/ejcts/ezy121. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1010-7940
eISSN
1873-734X
DOI
10.1093/ejcts/ezy147
Publisher site
See Article on Publisher Site

Abstract

Guidelines, Valve disease, Valve surgery, Percutaneous valve intervention, Aortic regurgitation, Aortic stenosis, Mitral regurgitation, Mitral stenosis, Tricuspid regurgitation, Tricuspid stenosis, Prosthetic heart valves The European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines on valvular heart disease [1] provide guidance for the diagnostic workup for patients with aortic stenosis and give recommendations for appropriate treatment strategies. Since the last version of the guideline in 2012, a huge amount of new evidence has been generated with regard to the risks and benefits of surgical aortic valve replacement and interventional transcatheter aortic valve implantation (TAVI) treatment for severe aortic stenosis. Although for inoperable patients and patients with high surgical risk TAVI has evolved as the therapy of choice if no anatomical or technical criteria render a transcatheter approach impossible, for intermediate risk patients, the available studies demonstrate equipoise with regard to the primary outcome. It is made very clear in the guidelines that the decision to perform surgical aortic valve replacement or TAVI cannot be based on a single number such as age or the EuroSCORE alone. Rather, the decision relies on an iterative process that takes all the factors into account that have a possible impact on the outcomes. Hence, the joint task force of ESC and EACTS tried to define an algorithm to rationalize the use of either therapy in this particular patient cohort. In the centre of this algorithm stands the local heart team that has to address the complex interaction of individual risk factors, comorbidities, technical feasibility and expected early and long-term outcomes that are specific for each procedure. In most trials, the lower cut-off for ‘intermediate risk’ was chosen to be 4% by the Society of Thoracic Surgeons (STS) or EuroSCORE II. Patients with risk scores lower than this cut-off were largely excluded. The task force was totally aware of the fact that this definition represents an arbitrary cut-off that is not supported by a large body of literature. In the absence of a better stratification model, it was, however, decided to follow these lines as evidence has accumulated around them. This does by no means imply that every patient in the intermediate risk group with the EuroSCORE II of 4% or higher should be treated with TAVI by default. This is also clearly stated in Table 7, which is designed to provide guidance for the decision-making process within the Heart Team. The authors refer to their own results in a group of patients with a mean EuroSCORE II of 1.93%, representing a low-risk group of patients [2]. For this cohort, the guidelines clearly recommend surgery. The authors confirm this recommendation by their excellent surgical results. The observed mortality of 1.43% leads to a favourable O:E ratio of 0.74 and, hence, proves that guideline adherence provides excellent outcomes. REFERENCES 1 Falk V , Baumgartner H , Bax J , DeBonis M , Hamm C , Holm PJ et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease . Eur J Cardiothorac Surg 2017 ; 52 : 616 – 64 . Google Scholar CrossRef Search ADS PubMed 2 Nezic DG , Petrovic I , Micovic S. How have task force members determined the threshold value of EuroSCORE II for an increased surgical risk in patients undergoing aortic valve interventions? Eur J Cardiothorac Surg 2018 ; doi:10.1093/ejcts/ezy121. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Sep 1, 2018

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