European Heart Journal Advance Access originally published online on October 2, 2008
European Heart Journal 2008 29(22):2822; doi:10.1093/eurheartj/ehn444
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Aortic valve stenosis management: old strategies and future directions: reply
Bichat Hospital, Cardiology
18 rue Henri Huchard
Paris 75018
France
Bichat Hospital, Cardiology
18 rue Henri Huchard
Paris 75018
France
Tel: +33 1 40 25 66 01
Fax: +33 1 40 25 88 65
Email: dominique.himbert{at}bch.aphp.fr
Bichat Hospital, Cardiology
18 rue Henri Huchard
Paris 75018
France
We would like to thank Dr Bottio et al. for their interest in our manuscript. In the letter, they pointed out that epidural anaesthesia could be used for cardiovascular surgery in high-risk patients. We agree with this statement, and, although we chose to intervene with general anaesthesia in this series, some centres usually perform transfemoral aortic valve implantations under locoregional anaesthesia, and others have already performed transapical aortic valve implantation under epidural anaesthesia. However, the main problem raised by these particular patients was not anaesthesia per se, but the fact that conventional aortic valve replacement was judged at very high risk or not technically feasible by the surgical team. Thus, we cannot agree with Dr Bottio et al. on the statement that ‘the main reason why percutaneous interventions are more acceptable by the patients is simplicity’, or that ‘interventional cardiologists and cardiac surgeons (team approach) are going to re-think the high-risk AS management without a well-founded clinical programme and forgetting the patients' and economic-community interests’. In fact, in our centre as in others, the team is not restricted to cardiologists and surgeons, but it also includes anaesthesiologists and geriatricians, who all participate in the final decision of whether or not to perform transcatheter aortic valve implantation. From a more general point of view, the clinical programmes concerning transcatheter aortic valve implantation for the treatment of patients with aortic stenosis have been clearly defined and detailed in the position statement from the European Association of Cardio-Thoracic Surgery and the European Society of Cardiology, in collaboration with the European Association of Percutaneous Cardiovascular Interventions, recently published in the journal.1 They will include prospective registries and controlled trials, the earliest of which have already been presented and discussed during many scientific meetings and congresses. Finally, the economic aspects of transcatheter aortic valve implantation have obviously not been forgotten. They raise difficult questions, joining the more general problem of medical care in the elderly. These questions will take on an increasing importance due to the ageing of the population, and solutions will have to be found at country level. However, it is now clear that, besides conventional open chest surgery, transcatheter interventions will play an increasingly important role in the treatment of valvular heart diseases in the future. In the same way, ‘old’ anaesthetic methods will certainly have to extend themselves to newer techniques, such as epidural anaesthesia.
The right future direction will be determined by ongoing dialogue between all the actors of the team, to define by consensus the best strategy for each individual patient.
Reference
- Vahanian A, Alfieri O, Al-Attar N, Antunes M, Bax J, Cormier B, Cribier A, De Jaegere P, Fournial G, Kappetein AP, Kovac J, Ludgate S, Maisano F, Moat N, Mohr F, Nataf P, Piérard L, Pomar JL, Schofer J, Tornos P, Tuzcu M, van Hout B, Von Segesser LK, Walther T. Transcatheter aortic valve implantation for patients with aortic stenosis: a position statement fro the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in collaboration with the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J (2008) 29:1463–1470.
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