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Aortic stenosis is one of the most common valvular conditions in Western countries and is steadily increasing with the ageing population in this part of the world. In the 1950s surgical valve replacement became available, initially with mechanical and later biological valves. Due to the risk of surgery, particularly in the elderly and frail,1 as well as in multimorbid individuals, the condition was undertreated. This changed with the introduction of transcatheter aortic valve implantation (TAVI), a novel procedure that is increasingly used in both the USA2 and Europe.3 At first, only inoperable patients were considered for the new procedure,4 then high-risk, intermediate-risk,5 and now even low-risk patients6,7—and development is consistently moving forward: 8 It is conceivable that in the near future, the majority of such patients will undergo TAVI rather than surgery. However, TAVI has to pass the test. The current situation is described in the FAST TRACK manuscript entitled ‘Transcatheter aortic valve implantation vs. surgical aortic valve replacement for treatment of symptomatic severe aortic stenosis: an updated meta-analysis’ by Stephan Windecker and colleagues from the University Hospital Bern in Switzerland.9 They extracted seven randomized trials with 8020 patients, interventions, and outcomes following pre-defined criteria, with all-cause mortality up to 2 years as the primary outcome. The combined mean STS score in the TAVI arm was 9.4, 5.1, and 2.0% for high-, intermediate-, and low-surgical risk trials, respectively. TAVI was associated with a significant reduction of all-cause mortality compared with surgical aortic valve replacement, with a hazard ratio of 0.88, an effect that was consistent across the entire spectrum of surgical risk and irrespective of the type of the TAVI valve system (Figure 1). TAVI resulted in lower risk of strokes, with a hazard ratio of 0.81, while surgery was associated with a lower risk of major vascular complications and permanent pacemaker implantations, with a hazard ratio of 2.27. Thus, compared with surgery, TAVI is associated with reduction in all-cause mortality and stroke up to 2 years irrespective of baseline surgical risk and type of TAVI system. These impressive results are put into clinical context in an Editorial by John Webb from St. Paul’s Hospital in Vancouver, Canada.10

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