The Partner Trial cohort A results clearly confirm the safety and efficacy of transcatheter aortic valve implantation (TAVI), whether inserted percutaneously or tans apically, compared to standard surgical AVR.  Despite excellent results in the surgical group, the TAVI patients did as well or better clinically, except for a higher peri-operative occurrence of stroke in these very high risk patients.  When considered along with the earlier Partner cohort B results in which the TAVI patients who were ineligible for surgery due to frailty or co-morbidities had better outcomes than medically treated patients, all of us, including the FDA, should confidently acknowledge that TAVI is an appropriate option for high risk, especially elderly, patients with severe aortic valve disease.

What these results do not tell us is how well these TAVI patients will do over a longer period than 1 year.  There are already, however, technical refinements to transcatheter valve devices being implanted outside of the US that will result in fewer strokes and procedural morbidity, reduced perivalvular leaks, and improved prosthesis durability.  Now that the clinical feasibility of percutaneous TAVI has been demonstrated so clearly in this FDA-mandated trial, we should expect rapid approval for wider availability of this first-generation transcatheter valve and other similar devices that are being implanted elsewhere.  As the medical device approval process in the US continues to plod along, many Americans are being denied the potential life-extending benefits of these innovations, while Europeans, Canadians and many others around the world are already receiving even newer modifications of the Sapien valve that was tested in the Partner Trial.

We had the “heart team” concept utilized in the excellent SYNTAX Trial comparing CABG surgery versus percutaneous intervention for patients with multi-vessel coronary artery disease.  In a similar vein, Mat Williams stresses the importance of the “heart valve team” for the evaluation and optimal treatment of high-risk patients with aortic valve disease.  Primary cardiologists need to be able to rely on interventionalists and surgeons, consulting together, to determine what treatment option is most appropriate for individual patients.  The collaboration between interventionalists and surgeons demonstrated in the Partner Trial should be the standard going forward.  Patients will not be served well if surgeons consider TAVI to be an encroachment on our territory or if interventionalists feel that they can take on any aortic valve patient for transfemoral TAVI. Many elderly patients will be more appropriate for TAVI while others are likely to do better, especially over longer periods, with surgery.  The Partner Trial has opened a new door and even a new era in the treatment of aortic valve disease.  It is time to focus on what is best for the individual patient and to avoid another turf war between surgeons and interventionalists.