Reply to Nezic et al.

Reply to Nezic et al. European Journal of Cardio-Thoracic Surgery 0 (2018) 1 LETTER TO THE EDITOR RESPONSE interaction of individual risk factors, comorbidities, technical feasibility and ex- pected 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% a,b, c Volkmar Falk * and Helmut Baumgartner by the Society of Thoracic Surgeons (STS) or EuroSCORE II. Patients with risk scores lower than this cut-off were largely excluded. Klinik fu ¨ r Herz-Thorax-Gefa ¨sschirurgie, Deutsches Herzzentrum Berlin, The task force was totally aware of the fact that this definition represents an Berlin, Germany arbitrary cut-off that is not supported by a large body of literature. In the ab- Klinik fu ¨ r Kardiovaskula ¨re Chirurgie, Charite, Berlin, Germany sence of a better stratification model, it was, however, decided to follow these Division of Adult Congenital and Valvular Heart Disease, Department of lines as evidence has accumulated around them. This does by no means imply Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany 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 Received 15 March 2018; accepted 18 March 2018 Table 7, which is designed to provide guidance for the decision-making pro- cess within the Heart Team. Keywords: Guidelines � Valve disease � Valve surgery � Percutaneous valve The authors refer to their own results in a group of patients with a mean intervention � Aortic regurgitation � Aortic stenosis � Mitral regurgitation � EuroSCORE II of 1.93%, representing a low-risk group of patients [2]. For this Mitral stenosis � Tricuspid regurgitation � Tricuspid stenosis � Prosthetic heart cohort, the guidelines clearly recommend surgery. The authors confirm this recommendation by their excellent surgical results. The observed mortality of valves 1.43% leads to a favourable O:E ratio of 0.74 and, hence, proves that guideline adherence provides excellent outcomes. 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 REFERENCES 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 [1] Falk V, Baumgartner H, Bax J, DeBonis M, Hamm C, Holm PJ et al. 2017 interventional transcatheter aortic valve implantation (TAVI) treatment for se- ESC/EACTS guidelines for the management of valvular heart disease. Eur vere aortic stenosis. J Cardiothorac Surg 2017;52:616–64. Although for inoperable patients and patients with high surgical risk TAVI [2] Nezic DG, Petrovic I, Micovic S. How have task force members deter- has evolved as the therapy of choice if no anatomical or technical criteria ren- mined the threshold value of EuroSCORE II for an increased surgical risk der a transcatheter approach impossible, for intermediate risk patients, the in patients undergoing aortic valve interventions? Eur J Cardiothorac available studies demonstrate equipoise with regard to the primary outcome. Surg 2018; doi:10.1093/ejcts/ezy121. It is made very clear in the guidelines that the decision to perform surgical aor- tic 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 *Corresponding author. Klinik fu ¨ r Herz-Thorax-Gefa ¨sschirurgie, Deutsches takes all the factors into account that have a possible impact on the outcomes. Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Hence, the joint task force of ESC and EACTS tried to define an algorithm to ra- Tel: +49-30-45932000; fax: +49-30-45932100; e-mail: falk@dhzb.de (V. Falk). tionalize 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 doi:10.1093/ejcts/ezy147 The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Downloaded from https://academic.oup.com/ejcts/advance-article-abstract/doi/10.1093/ejcts/ezy147/4985709 by Ed 'DeepDyve' Gillespie user on 12 July 2018 LETTER TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Abstract

European Journal of Cardio-Thoracic Surgery 0 (2018) 1 LETTER TO THE EDITOR RESPONSE interaction of individual risk factors, comorbidities, technical feasibility and ex- pected 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% a,b, c Volkmar Falk * and Helmut Baumgartner by the Society of Thoracic Surgeons (STS) or EuroSCORE II. Patients with risk scores lower than this cut-off were largely excluded. Klinik fu ¨ r Herz-Thorax-Gefa ¨sschirurgie, Deutsches Herzzentrum Berlin, The task force was totally aware of the fact that this definition represents an Berlin, Germany arbitrary cut-off that is not supported by a large body of literature. In the ab- Klinik fu ¨ r Kardiovaskula ¨re Chirurgie, Charite, Berlin, Germany sence of a better stratification model, it was, however, decided to follow these Division of Adult Congenital and Valvular Heart Disease, Department of lines as evidence has accumulated around them. This does by no means imply Cardiovascular Medicine, University Hospital Muenster, Muenster, Germany 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 Received 15 March 2018; accepted 18 March 2018 Table 7, which is designed to provide guidance for the decision-making pro- cess within the Heart Team. Keywords: Guidelines � Valve disease � Valve surgery � Percutaneous valve The authors refer to their own results in a group of patients with a mean intervention � Aortic regurgitation � Aortic stenosis � Mitral regurgitation � EuroSCORE II of 1.93%, representing a low-risk group of patients [2]. For this Mitral stenosis � Tricuspid regurgitation � Tricuspid stenosis � Prosthetic heart cohort, the guidelines clearly recommend surgery. The authors confirm this recommendation by their excellent surgical results. The observed mortality of valves 1.43% leads to a favourable O:E ratio of 0.74 and, hence, proves that guideline adherence provides excellent outcomes. 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 REFERENCES 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 [1] Falk V, Baumgartner H, Bax J, DeBonis M, Hamm C, Holm PJ et al. 2017 interventional transcatheter aortic valve implantation (TAVI) treatment for se- ESC/EACTS guidelines for the management of valvular heart disease. Eur vere aortic stenosis. J Cardiothorac Surg 2017;52:616–64. Although for inoperable patients and patients with high surgical risk TAVI [2] Nezic DG, Petrovic I, Micovic S. How have task force members deter- has evolved as the therapy of choice if no anatomical or technical criteria ren- mined the threshold value of EuroSCORE II for an increased surgical risk der a transcatheter approach impossible, for intermediate risk patients, the in patients undergoing aortic valve interventions? Eur J Cardiothorac available studies demonstrate equipoise with regard to the primary outcome. Surg 2018; doi:10.1093/ejcts/ezy121. It is made very clear in the guidelines that the decision to perform surgical aor- tic 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 *Corresponding author. Klinik fu ¨ r Herz-Thorax-Gefa ¨sschirurgie, Deutsches takes all the factors into account that have a possible impact on the outcomes. Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany. Hence, the joint task force of ESC and EACTS tried to define an algorithm to ra- Tel: +49-30-45932000; fax: +49-30-45932100; e-mail: falk@dhzb.de (V. Falk). tionalize 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 doi:10.1093/ejcts/ezy147 The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Downloaded from https://academic.oup.com/ejcts/advance-article-abstract/doi/10.1093/ejcts/ezy147/4985709 by Ed 'DeepDyve' Gillespie user on 12 July 2018 LETTER TO THE EDITOR

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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 25, 2018

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