Gustavo Rodriguez

Bioprosthetic valve dysfunction (BVD), hemodynamic valve dysfunction (HVD), and bioprosthetic valve failure (BVF): they may sound synonymous, but they are not. I tried to clarify the differences. The discussion also brought back the valve durability clock, which divided the panel. Some argued that it is not a major concern: we intervene earlier because intervention will eventually be necessary anyway. I somewhat disagree. To me, this is a conceptual and, to some extent, an ethical issue, particularly since we are not talking about a demonstrated mortality benefit of early intervention over clinical surveillance. Symptoms will eventually develop, but how soon? Moderate stenosis will eventually progress to severe stenosis, but over what timeframe? Intervening 1–2 years earlier in a patient whose life expectancy is shorter than the valve’s remaining durability is one thing. Intervening 5–6 years earlier in a patient who is likely to outlive the valve is quite another. In the latter scenario, I believe we should seriously question whether early intervention is preferable to clinical surveillance. Perhaps it is time to revisit the natural history studies of aortic stenosis, which certainly exist, to better understand the time course of progression from, e.g., moderate to severe stenosis, and from an asymptomatic state to the development of symptoms. #TCT2026