As Mat Williams stated, the Partner Trial, Cohort 2, compared patients, not eligible for surgery because of co-morbidities, to transcatheter aortic valve implantation (TAVI) versus optimal medical treatment. Results presented at the recent TCT and AHA meetings were unequivocally positive for TAVI in very elderly patients. These results and the favorable experience with TAVI in Europe portend a major paradigm change for the management of aortic valve disease in the elderly. We can be certain that TAVI will be widely used once it is approved for use in the US and after additional similar devices and refinements are available. The challenge for traditionally trained surgeons is reminiscent of what vascular surgeons faced in the early days of endovascular graft therapy for abdominal aneurysms; master the new techniques or risk becoming obsolete. For now, TAVI has been a real partnership between surgeons and interventional cardiologists. Surgeons have the choice of remaining partners in this complex endeavor, but to do so will require many of us to acquire skills that very few surgeons learn during training. The option will be backing up our interventional colleagues, managing their complications and being asked to operate only on the sickest patients.

How well the commendable collaboration between cardiologist and surgeon that existed in the Partner Trial survives once TAVI devices are fully accessible remains to be seen. Perhaps physician payment reform that will undoubtedly result from health care financing shortfalls will incent all relevant specialists to jointly recommend the most appropriate treatment for each patient. Regardless of how well the partnership endures, the clinical success of percutaneous valve replacement, as demonstrated in the Partner Trial, is another pivotal step in the development of additional effective options for treating more patients with aortic valve disease.