To the Editor,
Vázquez Rodríguez et al.1 elegantly demonstrate that transcatheter aortic valve implantation (TAVI) is cost-effective even in low-surgical risk patients. This cost-effectiveness adds to the excellent data regarding survival reported in real-life settings in Spain even in cohorts of very old patients with frequent comorbidities.2 Former data also confirm the cost-effectiveness of this technique,3-5 as well as its favorable outcomes,6 thus making it a viable option for low-risk patients as well.7
Therefore, in the management of symptomatic severe aortic stenosis where both surgical aortic valve replacement (SAVR) and TAVI are feasible options, and once the patient has been properly informed and given his/her written informed consent, he/she should be able to choose TAVI even if the heart team recommends SAVR. We should remember that 2 different domains exist regarding decision-making: the professional or objective domain that determines whether treatment is proportionate (and benefits can be expected), and the one pertaining to the patient, also called subjective domain, that determines whether the procedure is a common one (that is, not perceived as an unbearable aggression) (figure 1). Denying the decision-making capacity of a properly informed patient is unethical, and as noted by Vázquez Rodríguez et al.,1 cannot be justified from a financial standpoint either.
Figure 1. Two different decision-making domains: the professional or objective domain that determines whether treatment is proportionate, and the patient’s—subjective—who determines whether it is a common procedure. SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation.
FUNDING
None whatsoever.
CONFLICTS OF INTEREST
None reported.
REFERENCES
1. Vázquez Rodríguez J, Pinar Bermúdez E, Luis Zamorano J, et al. Cost-effectiveness of SAPIEN 3 transcatheter aortic valve implantation in low surgical mortality risk patients in Spain. REC Interv Cardiol. 2023;5:38-45.
2. Vicent L, Fernández-Cordón C, Nombela-Franco L, et al. Baseline ECG and Prognosis After Transcatheter Aortic Valve Implantation: The Role of Interatrial Block. J Am Heart Assoc. 2020;9:e017624.
3. Pinar E, García de Lara J, Hurtado J, et al. Cost-effectiveness analysis of the SAPIEN 3 transcatheter aortic valve implant in patients with symptomatic severe aortic stenosis. Rev Esp Cardiol. 2022;75:325-333.
4. Chotnoppharatphatthara P, Yoodee V, Taesotikul S, Yadee J, Permsuwan U. Transcatheter aortic valve implantation in patients with severe symptomatic aortic valve stenosis: systematic review of cost-effectiveness analysis. Eur J Health Econ. 2023;24:359-376.
5. Zhou JY, Liew D, Duffy SJ, Walton A, Htun N, Stub D. Cost-effectiveness of transcatheter versus surgical aortic valve replacement in low-risk patients with severe aortic stenosis. Heart Lung Circ. 2021;30:547-554.
6. UK TAVI Trial Investigators; Toff WD, Hildick-Smith D, Kovac J, et al. Effect of transcatheter aortic valve implantation vs surgical aortic valve replacement on all-cause mortality in patients with aortic stenosis: a randomized clinical trial. JAMA. 2022;327:1875-1887.
7. Lim GB. Suitability of TAVI in low-risk patients. Nat Rev Cardiol. 2023;20:284.
* Corresponding author.
E-mail address: mmselles@secardiologia.es (M. Martínez-Sellés).
