Dr. Gardner (as always!) raises excellent points.  This is indeed an exciting time for the treatment of patients with valve disease.  There is obviously a lot of excitement about TAVR for patients with AS.  I agree with Dr Gardner that we do need to temper our enthusiasm a little as there are some unanswered questions.  Just because TAVR is less invasive does not mean we should just widely adopt the technology.  We should remember that most patients with AS do EXTREMELY well with traditional surgery.  That being said the patients that are higher risk, elderly or frail will likely be treated with TAVR in the near future as first line therapy.  Prior to wider spread adoption we need to address some key issues.  First Dr. Gardener addresses the incidence of PVL.  There are some reports that the outcomes might be worse in patients with larger degrees of PVL.  While on one hand this makes sense I would caution the interpretation of these reports and we really need to follow this in a well designed study like PARTNER to truly understand the impact.  for example in the REVIVAL II study we did not see ventricular dilation even in those patients with >2+ PVL.  Going forward we need to do the best do minimize PVL.  I think this can be done by aggressive screening and choosing the correct valve size.  In some cases postdilating the valve might be effective.  Regardelss the higher incidence will still likely persist though it may be better addressed in newer generation devices.  We do need to follow this issue very closely to assure there is no deleterious ventricular changes and perhaps a higher incidence of hemolysis.

The stroke issue is one that continues to be highly debated.  This data was presented in more depth by Dr Miller a the AATS (as mentioned by Dr. Gardner).  I felt the most interesting finding was the fact that the patients in the TA Stratum (and thus those with no vascular access, i.e. the 'vasculopaths') was the best predictor for a neurologic event.  This is interesting since many have been saying for a few years that the TA procedure is protective for a neurological event.  It turns out it is more patient factors than the procedure.  Of course the TAVR procedures do carry a higher incidence of neurologic events (TA or TF).  Fortunately this is another area where I think we can improve.  There are new embolic protection devices that might prove to be effective.  Additionally I believe we need to better understand what might be the ideal post procedure anti-platelet and anti coagulant strategy.  The stroke issue does remain incredibly important and we need studies in lower risk patients with more intensive neurologic sub-studies before we can start more widely applying this technology.