Is watchful waiting still the default in asymptomatic severe AS?
Not always. EARLY TAVR randomised 901 patients with asymptomatic severe aortic stenosis to early TAVR or surveillance. Death, stroke or unplanned cardiovascular hospitalisation occurred in 26.8% with early TAVR and 45.3% with surveillance. Much of the benefit came from fewer cardiovascular hospitalisations rather than a large mortality difference.
What does long-term surgical evidence add?
In very severe asymptomatic aortic stenosis, early surgery showed a long-term advantage over conservative care. At ten years, operative mortality or cardiovascular death was 3% versus 24%, and all-cause death was 15% versus 32%. Patient selection remains central.
How durable is TAVR compared with surgery?
At seven years in low-risk severe AS, death, stroke or rehospitalisation occurred in 34.6% with TAVR and 37.2% with SAVR. Bioprosthetic valve failure was 6.9% and 7.5%, respectively. These results are reassuring, while lifetime valve planning remains important in younger patients.
Why is tricuspid regurgitation no longer forgotten?
TR is recognised as an independent marker of poor prognosis. Mechanistic classification—primary, atrial secondary, ventricular secondary and cardiac-device-associated—matters because it influences prognosis, imaging and treatment selection.
Assessment should integrate valve anatomy, regurgitation severity, right-sided remodelling, RV function and pulmonary pressures. Colour Doppler alone is not enough.
What did TRILUMINATE show?
Tricuspid TEER improved the hierarchical primary endpoint and quality of life. At 30 days, 87% of treated patients had moderate or less TR compared with 4.8% of controls. Death and heart-failure hospitalisation were not clearly reduced at one year; the strongest evidence is therefore for symptom and quality-of-life improvement.
The principle in secondary mitral regurgitation
Treat the ventricle first. Begin with guideline-directed therapy, CRT when indicated, treatment of ischaemia and rhythm management. Consider TEER when severe MR and symptoms persist despite optimisation in appropriately selected patients.
The overall shift is toward earlier intervention, better phenotyping, lifetime valve planning and shared decision-making—not intervention based on lesion severity alone.