The Changing Landscape of Aortic-Valve Stenosis Management

This NEJM editorial reviews the evolving management of aortic-valve stenosis, emphasizing two key decisions: when to intervene and how via surgical valve replacement or transcatheter aortic-valve replacement (TAVR). Severe aortic stenosis affects ~2.8% of adults >75 years, with no proven therapies to slow its progression, making timely valve replacement essential. The editorial highlights the 5-year results of the PARTNER 3 trial, comparing TAVR (SAPIEN 3 valve) with surgical replacement in low-risk patients. At 1 year, TAVR was superior (death/stroke/rehospitalization: 8.5% vs. 15.1%), but by 5 years, the difference narrowed and became non-significant (22.8% vs. 27.2%; P = 0.07). Valve durability and hemodynamic performance were similar across groups, with low rates of bioprosthetic failure (~3.3%) and paravalvular regurgitation (~0.9% moderate/severe). Mild paravalvular leak occurred more often with TAVR (19.9% vs. 3.2%), but did not impact survival. The editorial underscores cautious optimism: while early TAVR benefits may wane, valve durability and structural performance remain strong, informing shared decision-making across risk groups and age ranges.

This NEJM editorial reviews the evolving management of aortic-valve stenosis, emphasizing two key decisions: when to intervene and how via surgical valve replacement or transcatheter aortic-valve replacement (TAVR). Severe aortic stenosis affects ~2.8% of adults >75 years, with no proven therapies to slow its progression, making timely valve replacement essential. The editorial highlights the 5-year results of the PARTNER 3 trial, comparing TAVR (SAPIEN 3 valve) with surgical replacement in low-risk patients. At 1 year, TAVR was superior (death/stroke/rehospitalization: 8.5% vs. 15.1%), but by 5 years, the difference narrowed and became non-significant (22.8% vs. 27.2%; P = 0.07). Valve durability and hemodynamic performance were similar across groups, with low rates of bioprosthetic failure (~3.3%) and paravalvular regurgitation (~0.9% moderate/severe). Mild paravalvular leak occurred more often with TAVR (19.9% vs. 3.2%), but did not impact survival. The editorial underscores cautious optimism: while early TAVR benefits may wane, valve durability and structural performance remain strong, informing shared decision-making across risk groups and age ranges.