The evolving treatment of aortic stenosis: do new procedures provide new treatment options for the highest-risk patients?

The percutaneous treatment of valvular heart disease is rapidly progressing through clinical trials. For one valvular lesion, critical aortic stenosis, recent advances in technology and percutaneous techniques may potentially change the way in which we manage this disease in the most frail and elderly patients. Some of these new techniques blur the distinction between surgical and nonsurgical treatments. In this issue of Circulation, Lichtenstein and colleagues report the first series of patients to have an aortic valve implanted via a thoracotomy to expose the left ventricular apex, for subsequent sheath insertion, over-the-wire delivery system advancement, and image-guided implantation of a stent mounted equine crimped on a delivery balloon.1 This article is seminal in defining 2 major emerging issues: valvular heart disease treatments that are hybrids of surgical and catheter-based techniques and the challenges inherent in determining what treatment modalities are best in the growing problem of aortic stenosis in mature, ie, elderly, adults. This report adds to the recently published report from the St. Paul’s Hospital group in Vancouver using the retrograde percutaneous aortic valve (PAV) implantation technique.2