LAUSR

Rapid advances in transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) and edge‐to‐edge repair for mitral regurgitation have expanded the nonsurgical armamentarium for valvular heart disease complicated by profound hemodynamic compromise. The present study builds upon prior observations validating the potential benefits of TAVR for severe AS complicated by cardiogenic shock (CS). Analysis of a Nationwide Inpatient database identified 9899 hospitalizations from 2010 to 2019 managed “Invasively,” respectively by TAVR in 18%, balloon aortic valvuloplasty (BAV) in 20% or surgical aortic valve replacement in 62%. Key findings showed: (1) Shift over time to nonsurgical TAVR and BAV; (2) lower in‐hospital mortality for TAVR versus BAV; and (3), although outcomes improved over the time period studied, in‐hospital mortality remained high across the treatment strategies. The authors should be congratulated for sharpening the focus on interventional management of valvular heart disease complicated by life‐threatening hemodynamic deterioration. Of note, the present observations were drawn from a decade that witnessed dramatic evolution of TAVR technology and technique, resulting in more widespread applicability and improved procedural outcomes. Concurrently, the advent of adjunctive mechanical circulatory support (MCS) devices further enhanced hemodynamic management and facilitated high‐risk interventions. Yet the present report delivers both hope and despair, for the present findings are consistent with prior studies demonstrating that although TAVR in gravely ill patients can be life‐saving, complicating CS is an independent predictor of 30‐day and 1‐year mortality: Under these conditions, poor outcomes are driven by the clinical status of patients, not procedural complications. Taken together, these observations deliver a sobering admonition regarding the grim prognosis associated with the nature of CS in general, particularly in the setting of severe valvular disease. 2 | HEMODYNAMIC COMPROMISE IN AS: FOCUS BEYOND THE VALVE