Evaluating TAVI outcomes—not just a matter of life and death

Transcatherter aortic valve implantation (TAVI) has been widely adopted in Europe and in the USA as an alternative to surgical aortic valve replacement (SAVR) in patients with severe symptomatic aortic stenosis (AS) at high or prohibitive surgical risk. Unfortunately, although proven in many trials and registries as a safe and effective treatment, many of the patients undergoing TAVI are at the extremes of age and illness, thereby not deriving significant long-term benefit in terms of life expectancy or quality of life (QOL). For example, among patients at prohibitive surgical risk treated with TAVI in the PARTNER IB trial, 30% were dead at 1 year and approximately one-half were deceased or had less than moderate improvement in their quality of life or New York Heart Association (NYHA) functional class (1). Furthermore, the public expenditure has been enormous and is rapidly rising, mostly owing to therapy offered to patients who would not have been offered treatment in the pre-TAVI era. This has raised a continuing interest in strategies to improve pre-TAVI patient selection in order to minimize “futility” (i.e., ineffective TAVI procedures) and improve cost-effectiveness.