Reply to Kalavrouziotis et al.

With interest we read the comments made by Kalavrouziotis et al. on the two recent papers on transapical aortic valve implantation [1]. The authors comment on the EuroSCORE. We are aware that the operative risk may be overestimated when using the EuroSCORE, particularly in patients with a high-risk profile. However, the EuroSCORE is a well-accepted, scientifically validated tool that has been assessed in numerous publications. We therefore believe it should be used in such studies, at least as one method of quantifying preoperative risk. In the future, we will also be using the STS score. Use of a standardized scoring system allows for uniform comparison of different patient groups across studies and should therefore lead to improved scientific reporting, accuracy and understanding of these investigational devices. The consideration that a high-risk profile may be prohibitive for conventional valve replacement is an important aspect to discuss. In our practice, we rarely deem a patient suffering from symptomatic aortic valve stenosis as ‘inoperable’. Therefore, even a high-risk profile would not be prohibitive for conventional aortic valve surgery in most patients at our institution. It has been well described in the literature that these high-risk operations can be performed with reasonable rates of morbidity and mortality, and our personal experience confirms this. However, when discussing high-risk patients, we have to consider several aspects. We must evaluate the individual patient’s potential risk and benefit for every operation. This includes weighing the likelihood of improvement in quality of life and life expectancy gained against the perioperative risk. We usually include the patients’ relatives in such decisions. Although conventional surgery can be successfully performed in high-risk patients, the rates of morbidity and mortality are far from zero and potential alternative techniques should be investigated. One method of decreasing the perioperative risk may be the new transapical beating heart approach, which we investigated in our initial feasibility study. If we are to continue making advances in the field of cardiac surgery, then we must continue to be innovative and assess alternative methods of treatment, particularly in patients at increased risk for poor outcomes. We would like to express our gratitude for the authors’ comments because this is exactly what we need—further surgical interest in and discussion about these exciting new techniques. We can only comment on what we are currently doing in Europe and cannot comment on the experiences of the Vancouver group. However, we consider almost every patient with symptomatic aortic valve stenosis as operable and we are scientifically evaluating new means to decrease their perioperative risk. The study presented [2] is a feasibility trial that was ethically approved after developing a sound scientific background. Further randomized trials are under way. Transcatheter valve implantation is an evolving field and surgeons should be part of it [3].

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