It seems that in the future, TAVI will not be offered to some of the most severely ill excellent validation patients who have had very short survival times despite successful TAVI. Screening is routinely performed for carotid and coronary atherosclerosis. Renal function is

evaluated and optimized if possible, and pulmonary function is critically assessed. Intraoperative management has progressed considerably with regard Inhibitors,research,lifescience,medical to stroke avoidance and pulmonary complications. Myocardial protection and management of the significant diastolic dysfunction routinely seen in these patients is better understood. Postoperative care has undergone a complete revolution in the last 10 years. Our patients receive care 24 hours a day by our in-house, Inhibitors,research,lifescience,medical full-time CV surgical intensivist team. This has led to superior management of the postoperative period. Programmatic goals to avoid ventilator-dependent pneumonia, ICU-acquired infections, sepsis, and excessive blood usage have all had incremental benefit. Aggressive and early management of hemodynamic instability with prompt availability Inhibitors,research,lifescience,medical of echocardiography has assisted these patients. Early mobilization, nutritional support, and a Sutent formal perioperative physical therapy program have aided recovery. Thus, significant improvements in care have lowered the historical

morbidity and mortality of these elderly patients. The commitment to a collaborative team-based approach is essential for the care of these critically ill patients. Expansion of Indications for TAVI Expanding the role of TAVI from treatment of inoperable patients with aortic stenosis to other less-sick populations has been studied in two randomized prospective trials. Inhibitors,research,lifescience,medical In the PARTNER Cohort A trial for high-risk patients, described in detail above, the conventional AVR results were competitive with TAVI at 1 year in terms of mortality.6 However, excess stroke and paravalvular leaks remain a

problem in TAVI patients. The ultimate magnitude Inhibitors,research,lifescience,medical of these problems and the risk of progressive aortic insufficiency will be answered by ongoing follow-up for the Cohort A, such as the 2-year data mentioned above for the Cohort B patients. In a study of stroke after TAVI in 253 patients, Tay et al.17 showed that while the incidence of stroke was highest in the first 24 hours, it remained high for 2 months post-procedure. Proposed mechanisms Entinostat for perioperative strokes included embolization of atheromatous or calcific debris and periprocedural hypotension. Later strokes were attributed to thrombus formation on the prosthesis or in periprosthetic spaces. The STACCATO trial18 compared transapical TAVI with surgical AVR in elderly patients (mean age: TAVI 80±3.6 and AVR 82±4.4 years), all of whom had severe aortic stenosis but who were otherwise not at an elevated risk for surgical AVR. The mean STS score was 3.3.