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  • Editorial: Surgery Versus Transcatheter Veers Right

    Transcatheter aortic valve replacement (TAVR) has grown at a tremendous rate and fundamentally changed the landscape for aortic stenosis. Attempting to replicate this success for the other cardiac valves is currently a goal for the field of structural heart disease. Each of the other valves has unique qualities making transcatheter approaches more complex than the aortic valve, and the pulmonary valve is no exception. Most cases requiring intervention for pulmonary valve dysfunction are for congenital defects and, thus, cluster in young patients rather than the elderly patients that TAVR started with. Right ventricular outflow obstruction (RVOT) is seen in a variety of congenital defects such as Tetralogy of Fallot, conotruncal defects, and congenital stenosis. Initial surgical repair can often show late RVOT dysfunction of stenosis or insufficiency. Surgical correction of these defects had been the only option other than medical care until 2000, when a bovine jugular valve conduit was sewn inside of a balloon-expanded metal frame was used to correct pulmonary stenosis in a young patient [  ]. This led to the development and eventual US Food and Drug Administration (FDA) approval of the Melody valve for the transcatheter treatment of pulmonary valve dysfunction. This valve required pre-stenting with a metal balloon-expanded stent to create a landing zone for the valve to mitigate frame fracture of the implanted valve. The two most feared complications are coronary artery obstruction and conduit rupture. Both have decreased in occurrence with increasing experience, and both have potential transcatheter solutions. Borrowing from the TAVR world, the balloon-expanded Sapien XT and now Sapien 3 have been used and are now FDA-approved for this indication. Neither require pre-stenting, but the potential for coronary obstruction and conduit rupture exists for these valves also. Procedural success with these valves tends to be >95%. Comparing the transcatheter approach to open surgical valve replacement has been difficult, as these often represent different groups, and head-to-head comparisons are uncommon. A recent comparison of 66 patients (36 transcatheter and 30 surgical) showed no difference in mortality, cardiovascular hospital admissions, or reinterventions [  ]. A meta-analysis and review of the literature including 4939 surgical cases and 1132 transcatheter cases found no difference in mortality but higher procedural complications and length of stay for the surgical group [  ]. In this issue of the journal, Megaly and co-authors expand our knowledge of these approaches [  ].

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