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Practice Rapid Recommendations

Transcatheter or surgical aortic valve replacement for patients with severe, symptomatic, aortic stenosis at low to intermediate surgical risk: a clinical practice guideline

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i5085 (Published 28 September 2016) Cite this as: BMJ 2016;354:i5085
Choice of intervention for those with severe aortic stenosis Recommendations or Transcatheter aortic valve implantation Transfemoral TAVI Surgical aortic valve replacement SAVR Open-heart surgery, to remove the narrowed aortic valve. Replacement with tissue valve. Inserting a new valve into the aortic valve’s place without open heart surgery. Delivery is through the femoral artery. Population Favours TAVI Favours SAVR

Age 85+ Why? Strong Benefits outweigh harms for almost everyone.All or nearly all informed patients would likely want this option.

Comparison of benefits and harms Events per 1000 people – within 2 years Length of hospital stay Quality of evidence Favourstransfemoral TAVI Favours SAVR The uncertainty around long-term durability of TAVI valves is not likely to concern those over 85. These older patients are also likely to place a high value on avoiding open heart surgery. TAVI is likely to be a cost-effective alternative to SAVR for patients at low to moderate perioperative risk, but we have not identified any cost-effectiveness analyses to support this. Preferences and values Resourcing Only centres with sufficient expertise and an established TAVI team with experienced general and interventional cardiologists and cardiac surgeons should offer TAVI. Other Deaths Moderate / severe heart failure Strokes Life-threatening bleeds New onset atrial fibrillation Median days in hospital Pacemaker insertions Aortic valve reinterventions Aortic valve reinterventions 197 45 fewer 20 fewer 252 fewer 178 fewer 79 10 226 161 134 87 8 242 Events per 1000 people – within 10 years 226 99 3 92 413 312 69 12 7 fewer 134 fewer 18 fewer 4 fewer 92 134 fewer Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Very low Very low quality evidence Any estimate of effect is very uncertain. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. See all 14 outcomes

Age 75–84 Why? Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option.

Comparison of benefits and harms Events per 1000 people – within 2 years Length of hospital stay Quality of evidence Favourstransfemoral TAVI Favours SAVR People who wish to avoid open-heart surgery are likely to favour TAVI. People who place more value on avoiding a second aortic valve placement are likely to choose surgery. Preferences and values Resourcing Only centres with sufficient expertise and an established TAVI team with experienced general and interventional cardiologists and cardiac surgeons should offer TAVI. Other Deaths Moderate Moderate / severe heart failure Strokes Life-threatening bleeds New onset atrial fibrillation Median days in hospital Pacemaker insertions Aortic valve reinterventions 122 30 fewer 20 fewer 252 fewer 178 fewer 79 10 226 161 134 87 8 152 Events per 1000 people – within 10 years Aortic valve reinterventions Very low 198 99 3 92 413 312 69 12 7 fewer 134 fewer 18 fewer 4 fewer 61 137 fewer Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. Very low Very low quality evidence Any estimate of effect is very uncertain. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. See all 14 outcomes TAVI is likely to be a cost-effective alternative to SAVR for patients at low to moderate perioperative risk, but we have not identified any cost-effectiveness analyses to support this.

Age 65–74 Why? Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option.

Comparison of benefits and harms Events per 1000 people – within 2 years Length of hospital stay Quality of evidence Favourstransfemoral TAVI Favours SAVR People who wish to avoid open-heart surgery are likely to favour TAVI. People who place more value on avoiding a second aortic valve placement are likely to choose surgery. Preferences and values Resourcing Only centres with sufficient expertise and an established TAVI team with experienced general and interventional cardiologists and cardiac surgeons should offer TAVI. Other Deaths Moderate / severe heart failure Strokes Life-threatening bleeds New onset atrial fibrillation Median days in hospital Pacemaker insertions Aortic valve reinterventions 73 19 fewer 14 fewer 252 fewer 178 fewer 56 10 226 161 134 87 8 92 Events per 1000 people – within 10 years Aortic valve reinterventions Very low 198 70 3 92 413 312 69 12 7 fewer 134 fewer 18 fewer 4 fewer 61 137 fewer Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Very low Very low quality evidence Any estimate of effect is very uncertain. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. See all 14 outcomes TAVI is likely to be a cost-effective alternative to SAVR for patients at low to moderate perioperative risk, but we have not identified any cost-effectiveness analyses to support this.

Age under 65 Why? Strong Benefits outweigh harms for almost everyone.All or nearly all informed patients would likely want this option.

Comparison of benefits and harms Events per 1000 people – within 2 years Length of hospital stay Quality of evidence FavoursTransfemoral TAVI Favours SAVR Since durability of TAVI valves is unknown, younger people may place a high value on avoiding a second aortic valve placement. Preferences and values Resourcing Only centres with sufficient expertise and an established TAVI team with experienced general and interventional cardiologists and cardiac surgeons should offer TAVI. Other Deaths Moderate / severe heart failure Strokes Life-threatening bleeds New onset atrial fibrillation Median days in hospital Pacemaker insertions Aortic valve reinterventions 57 15 fewer 10 fewer 252 fewer 57 fewer 40 10 226 161 43 87 8 72 Events per 1000 people – within 10 years Aortic valve reinterventions 198 50 3 92 413 100 69 12 7 fewer 134 fewer 18 fewer 4 fewer 61 137 fewer Low Low quality evidence We have only low confidence in the evidence supporting the recommendation. Further research is very likely to have an important impact, which is likely to change the estimate of effect. Low Low quality evidence We have only low confidence in the evidence supporting the recommendation. Further research is very likely to have an important impact, which is likely to change the estimate of effect. Low Low quality evidence We have only low confidence in the evidence supporting the recommendation. Further research is very likely to have an important impact, which is likely to change the estimate of effect. Low Low quality evidence We have only low confidence in the evidence supporting the recommendation. Further research is very likely to have an important impact, which is likely to change the estimate of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Low Low quality evidence We have only low confidence in the evidence supporting the recommendation. Further research is very likely to have an important impact, which is likely to change the estimate of effect. Very low Very low quality evidence Any estimate of effect is very uncertain. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. See all 14 outcomes TAVI is likely to be a cost-effective alternative to SAVR for patients at low to moderate perioperative risk, but we have not identified any cost-effectiveness analyses to support this.
Key uncertainties The major uncertainty is the durability of TAVI valves which drives recommendations in favour of SAVR in younger patients.
Choice of intervention for people with severe aortic stenosiswho are unsuitable for TAVI by transfemoral approach Recommendations or Open-heart surgery, to remove the narrowed aortic valve. Replacement with tissue valve. A more direct delivery of the new valve, through the 6th or 5th intercostal space, into the the left ventricle. Population Favours TAVI Favours SAVR Transcatheter aortic valve implantation Transapical TAVI Surgical aortic valve replacement SAVR

All ages Why? Strong Benefits outweigh harms for almost everyone.All or nearly all informed patients would likely want this option.

Comparison of benefits and harms Events per 1000 people – within 2 years Length of hospital stay Quality of evidence Favourstransapical TAVI Favours SAVR Patients are likely to place a high value on the reduced risk of deaths and stroke with SAVR. There is also more certainty around the durability of valves used. Surgery is likely to constitute a cost-effective alternative to transapical TAVI, but we have not identified any cost-effectiveness analyses to support this. Preferences and values Resourcing Only centres with sufficient expertise and an established TAVI team with experienced general and interventional cardiologists and cardiac surgeons should offer TAVI. Other Deaths Moderate Moderate / severe heart failure Strokes Life-threatening bleeds New onset atrial fibrillation Median days in hospital Pacemaker insertions Aortic valve reinterventions 253 194 fewer 178 fewer 112 10 226 219 134 87 8 Events per 1000 people – within 10 years Aortic valve reinterventions 198 3 92 413 312 69 12 7 fewer 134 fewer 18 fewer 4 fewer 61 137 fewer 57 fewer 45 fewer 196 67 Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Low Low quality evidence We have only low confidence in the evidence supporting the recommendation. Further research is very likely to have an important impact, which is likely to change the estimate of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. High High quality evidence We are very confident in the evidence supporting the recommendation. Further research is very unlikely to change the estimates of effect. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. Very low Very low quality evidence Any estimate of effect is very uncertain. Moderate Moderate quality evidence We are moderately confident in the evidence supporting the recommendation. Further research could have an important impact, which may change the estimates of effect. See all 14 outcomes

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Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Per O Vandvik, associate professor1 2,
  2. Catherine M Otto, professor3,
  3. Reed A Siemieniuk, methodologist4 5,
  4. Rodrigo Bagur, assistant clinical professor6,
  5. Gordon H Guyatt, distinguished professor4 7,
  6. Lyubov Lytvyn, methodologist8,
  7. Richard Whitlock, associate professor9 10,
  8. Trond Vartdal, consultant physician11,
  9. David Brieger, professor12,
  10. Bert Aertgeerts, professor13,
  11. Susanna Price, professor14,
  12. Farid Foroutan, graduate student4 15,
  13. Michael Shapiro, community representative and senior health informaticist for RTI International16,
  14. Ray Mertz, community representative17,
  15. Frederick A. Spencer, professor4 7
  1. 1Institute of Health and Society, Faculty of Medicine, University of Oslo, 0318 Oslo, Norway
  2. 2Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
  3. 3Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA 98195
  4. 4Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  5. 5Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Division of Cardiology, London Health Sciences Centre and Department of Epidemiology & Biostatistics, Western University, London, Ontario, Canada N6A 3K7
  7. 7Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  8. 8Systematic Overviews through advancing Research Technology, Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario Canada M5G 0A4
  9. 9Department of Surgery, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  10. 10Population Health Research Institute, Hamilton, Ontario, Canada L8L 2X2
  11. 11Department of Cardiology, Oslo University Hospital – Rikshospitalet, 0424 Oslo, Norway
  12. 12Concord Repatriation General Hospital, Concord, New South Wales 2139, Australia
  13. 13Department of Public Health and Primary Care, KU Leuven, 3000 Leuven, Belgium
  14. 14Royal Brompton Hospital, London SW3 6NP, UK
  15. 15Heart Failure/Transplant Program, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada M5G 2C4
  16. 16Chicago, Illinois, USA
  17. 17London, Ontario, Canada
  1. Corresponding author: P O Vandvik per.vandvik{at}gmail.com

In patients with symptomatic severe aortic stenosis but at lower risk of perioperative death, how do minimally invasive techniques compare with open surgery? Prompted by a recent trial, an expert panel produced these recommendations based on three linked rapid systematic reviews

What you need to know

  • New trial evidence confirms that transcatheter aortic valve insertion (TAVI), initially developed for patients with severe aortic stenosis who were unfit for surgical aortic valve replacement (SAVR), can be offered also to patients at low to intermediate surgical risk

  • Long term durability of TAVI valves remains highly uncertain

  • Age stratified recommendations reflect that TAVI is probably preferable to those over 75 years old, whereas SAVR is likely preferable to those under 75 years

A randomised controlled trial of transcatheter aortic valve insertion (TAVI) versus surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis was published in April 2016. The Partner 2 trial included 2032 people at intermediate surgical risk and favoured TAVI over open SAVR at two years for some outcomes.1 It had the potential to change practice.

Before the availability of TAVI, the only effective treatment for symptomatic severe aortic stenosis was SAVR with mechanical or bioprosthetic valves (fig 1⇓). In practice, patients offered mechanical valves tend to be younger and must accept lifelong anticoagulation. The minimally invasive option, TAVI, was developed for patients who are unfit for surgery, in whom its use is recommended by major US and European guidelines.2 3

Figure1

Fig 1 Flowchart for management of severe aortic stenosis (AS). Coloured boxes represent the recommendations covered by this article. AVR=aortic valve replacement, SAVR=surgical aortic valve replacement, TAVI=transcatheter aortic valve insertion

Severe aortic stenosis affects approximately 3 in 100 people over the age of 75 years.4 Patients typically experience symptoms of heart failure and reduced quality of life. Without aortic valve replacement, life expectancy is typically 50% at two years, with escalation of heart failure and reduced quality of life.5 These recommendations are for patients with symptoms and severe aortic stenosis: patients without symptoms or with milder disease are not considered here. Box 1 shows the linked articles in this BMJ Rapid Recommendations cluster.

Box 1: Linked articles in this BMJ Rapid Recommendations cluster

  • Siemieniuk RA, Agoritsas T, Manja V, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic stenosis at low and intermediate risk: systematic review and meta-analysis. BMJ 2016;354:i5130. doi:10.1136/bmj.i5130

  • Foroutan F, Guyatt GH, O’Brien K, et al. Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies. BMJ 2016;354:i5065. doi:10.1136/bmj.i5065

  • Lytvyn L, Guyatt GH, Manja V, et al. Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review. BMJ Open 2016;6:e014327. doi:10.1136/bmjopen-2016-014327

  • Editorial: Siemieniuk RA, Macdonald H, Agoritsas T, Guyatt GH, Vandvik PO. Introduction to BMJ Rapid Recommendations. BMJ 2016;354:i5191, doi:10.1136/bmj.i5191.

  • Magic App (www.magicapp.org/public/guideline/aEeKpL)

    • Expanded version of the results with multilayered recommendations, evidence summaries, and decision aids for use on all devices

How the recommendations were created

The international expert panel included front line and intervention cardiologists, a heart surgeon, internists, a general practitioner, methodologists, and people with lived experience of the condition (see list of panel members). To avoid bias, we excluded people with a professional, academic, or financial conflict of interest that we judged as excessive (see online methods supplement, competing interests statement, and appendix of interests of the panel members).

The panel followed standards for trustworthy guidelines and used the GRADE methodology to critically appraise the evidence and to create recommendations.6 7 8 When moving from evidence to recommendations, the panel integrated information on benefits and harms of treatment alternatives, quality of evidence, and values and preferences of patients as well as acceptability, feasibility, and resources (see box 1). Estimates of absolute effects are derived from relative effect estimates from the systematic review coupled with the best population estimates of baseline risks derived from a linked systematic review of observational studies.9 We label recommendations for or against each alternative as either weak or strong (see infographic).

The evidence

A linked systematic review and meta-analysis combines the data from the Partner 2 trial with three other trials (see fig 2⇓). It pools data on 3128 patients with symptomatic severe aortic stenosis at low or moderate risk of perioperative death, typically followed for two years.1 10 11 12 13 14

Figure2

Fig 2 Patient and trial characteristics in the four trials of the linked meta-analysis10

Compared with SAVR, transfemoral TAVI reduced mortality and stroke, life threatening bleeds, atrial fibrillation, and acute kidney injury at two years, but increased heart failure, major vascular complications, pacemaker insertion, and need for aortic valve reintervention within 2 years (see infographic).10 In contrast, transapical TAVI may increase mortality and stroke compared with the surgical approach. The results for mortality, stroke, and acute kidney injury were based on a subgroup analysis for transfemoral versus transapical approach, deemed credible by the review authors according to specific criteria.15

Estimates of baseline risk for most outcomes came from a linked systematic review on prognosis for patients undergoing SAVR.9

The panel were reasonably confident that the absolute effect sizes for the short term benefit and harm of TAVI and SAVR were true and accurate estimates (that is, overall moderate certainty according to GRADE). But the panel were very uncertain about the long term durability of the valves used in TAVI, particularly with respect to their recommendations in younger patients with a longer predicted life expectancy. The low certainty in the estimated long term re-intervention rate after TAVI of approximately 27 in 100 people reflects an absence of published follow-up studies beyond five years.

The linked systematic review on values and preferences yielded extremely limited evidence to inform the recommendations, particularly their strength.16 There are no studies on patients deciding between TAVI and SAVR, although one study evaluated patient preferences and values when deciding whether to undergo SAVR (versus no surgery).16 17 One study identified multiple biomedical, functional, social, and environmental factors influencing patients’ decisions to undergo assessment for TAVI.18 Overall, there is evidence of variability in individual values and preferences, highlighting the need for shared decision making, particularly for patients aged between 65 and 85 years.

Practical considerations

Perioperative risk is typically assessed by expert cardiovascular teams. Validated risk scores such as the STS-PROM are available online (www.riskcalc.sts).

Type of device and TAVI approach may vary: balloon expandable and self expanding devices can be used via transfemoral, subclavian, direct aortic, transcarotid, or transapical (balloon only) routes.

Fig3⇓ lists issues that may influence a person’s choice of procedure. These are further detailed in MAGICapp within the consultation decision aids that provide all desirable and undesirable consequences of treatment options.

Figure3

Fig 3 Practical considerations that may influence a patient’s choice of procedure. For a complete list, see decision aids in the MAGICapp (www.magicapp.org/public/guideline/aEeKpL)

Costs and resources

There are no cost effectiveness data for patients at low to intermediate surgical risk considering TAVI versus SAVR. Both procedures are resource demanding and require an experienced cardiovascular team (table 1⇓). In general, TAVI devices are more expensive than surgery, but this extra cost may be partially offset by a slightly shorter hospital stay and less need for post-discharge rehabilitation.

Table 1

Facilities and teams required for transcatheter aortic valve insertion (TAVI) versus surgical aortic valve replacement (SAVR)*

View this table:

Future research

Future recommendations and guidelines would benefit from studies that answer the following questions

  • Qualitative or survey study. What are the values and preferences of patients deciding between TAVI and SAVR, particularly with respect to uncertain durability of TAVI devices, the desire to avoid open heart surgery, and post-procedure pain and recovery time?

  • What is the durability of the TAVI valves beyond five years?

How patients were involved in the creation of this article

Two people with lived experience of severe aortic stenosis were full panel members and contributed with their experience and perspectives throughout the Rapid Recommendations process. Initially the community panel members identified pain and recovery time (in addition to already identified outcomes) and practical issues as important for choosing between TAVI and SAVR. They also fully participated in teleconferences and email exchange to discuss the evidence, draft recommendations, and to provide feedback in the creation of this article.

Footnotes

  • This BMJ Rapid Recommendations article is one of a series that provides clinicians with trustworthy recommendations for potentially practice changing evidence. BMJ Rapid Recommendations represent a collaborative effort between the MAGIC group (www.magicproject.org) and The BMJ. A summary is offered here and the full version including decision aids is on the Magic app (www.magicapp.org), for all devices in multilayered formats. Those reading and using these recommendations should consider individual patient circumstances such as frailty, overall life expectancy, and relevant comorbidity, and their values and preferences. We encourage adaptation of recommendations to allow contextualisation of recommendations and to reduce duplication of work. Those considering use or adaptation of content may go to MAGICapp to link or extract its content or contact The BMJ for permission to reuse content in this article. Series adviser Rafael Perera-Salazar

  • Competing interests: All authors have completed the BMJ Rapid Recommendations interests form. The BMJ Rapid Recommendations team judged that no panel member declared financial, professional, or academic interests that precluded authorship. The declared interests for each panel member are attached. No panel members declared any financial conflicts of interest related to this clinical question, specifically no financial ties to the heart valve industry. D Brieger receives personal and institutional research funding from industry, none relevant for TAVI or SAVR (has received funding from Eli Lilly, Astra Zeneca, Sanofi Aventis, Boerhinger Ingelheim, Pfizer, Merck Sharp and Dohme, Bristol-Myers Squibb, and Bayer all related to antithrombotic or diabetes therapy). R Whitlock has received funding for consulting with Atricure and Armetheon (both focus on atrial fibrillation management). R Bagur is a primary investigator of a trial on anticoagulation in atrial fibrillation, sponsored by Bristol-Myers Squibb. R Whitlock performs SAVR. R Bagur performs TAVI. CM Otto has co-chaired the American College of Cardiology guidelines on valvular heart disease, which includes TAVI, and is the UpToDate editor on the same topic. R Whitlock is the section lead for the American College of Chest Physicians valve guidelines. S Price is a panel member of the European Cardiology Society guidelines on heart valves. RA Siemieniuk, GH Guyatt, PO Vandvik, CM Otto, R Bagur, F Foroutan, and L Lytvyn participated in writing the complementary systematic reviews that formed the evidence base for this guideline. No panel member has previously formally made statements favouring either option in low or intermediate perioperative risk patients. This article was edited by H MacDonald at The BMJ who had no relevant financial or intellectual interests.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

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