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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
MRI in patients with pacemakers or implantable cardioverter-defibrillators (March 2017)
Potential risks of magnetic resonance imaging (MRI) in patients with permanent pacemakers or implantable cardioverter-defibrillators (ICDs) include programming changes, pacing abnormalities, and induced currents in lead wires. In a prospective multicenter trial, 1500 nonthoracic MRI examinations were performed in a 1.5T magnet on patients with a non-MRI-conditional pacemaker or ICD that had been programmed according to a standardized protocol; no device or lead failures were observed . While these reports are reassuring, the presence of a pacemaker or ICD is still generally considered a strong relative contraindication to routine MRI. (See "Principles of magnetic resonance imaging", section on 'Permanent pacemakers and implantable cardioverter-defibrillators'.)
Risk of sudden cardiac death in patients with HCM and LV apical aneurysms (February 2017)
Patients with hypertrophic cardiomyopathy (HCM) have an increased risk of death from several causes, including ventricular tachycardia (VT) resulting in sudden cardiac death (SCD). Clinical evaluation for five established major risk factors (ie, syncope, nonsustained VT, massive left ventricular hypertrophy, abnormal blood pressure response to exercise, and family history of SCD) helps to identify patients for whom an implantable cardioverter defibrillator (ICD) may be warranted for primary prevention of SCD. A recent paper supports an additional criterion for ICD placement . In this study, patients with HCM and a left ventricular (LV) apical aneurysm, compared with patients without an LV apical aneurysm, had five times the risk of VT and SCD. Patients with HCM and an LV apical aneurysm should receive strong consideration for ICD placement, as well as radiofrequency ablation for recurrent VT, if present. (See "Hypertrophic cardiomyopathy: Assessment and management of ventricular arrhythmias and sudden cardiac death risk", section on 'Established high-risk clinical features'.)
Emergency coronary catheterization following sudden cardiac arrest (February 2017)
Emergency coronary catheterization is indicated for patients who sustain sudden cardiac arrest (SCA) and manifest signs of an acute coronary syndrome (ACS), such as ST elevation on their electrocardiogram. However, whether coronary catheterization should be performed in SCA patients without such signs remains controversial. A meta-analysis of 11 heterogeneous, retrospective studies involving several thousand patients found that over 30 percent of post-arrest patients with no ST elevation had acute coronary artery occlusions regardless of their presenting rhythm . While randomized trials are needed to address this question, we believe it is reasonable to perform coronary catheterization in SCA patients without discrete signs of ACS, provided resources to do so are available. (See "Post-cardiac arrest management in adults", section on 'Coronary revascularization'.)
Dabigatran combined with certain statins associated with increased risk of major bleeding (February 2017)
An analysis of health records of nearly 46,000 Canadian patients showed that older adults (age ≥66) with atrial fibrillation taking dabigatran who also received simvastatin or lovastatin had approximately a 50 percent greater risk of hospitalization for major hemorrhage relative to those who used other statins . Although the mechanism for this interaction is uncertain, until additional information becomes available, it may be prudent to choose a statin other than lovastatin or simvastatin for older patients receiving dabigatran, and for those with an elevated risk for serious bleeding. (See "Statins: Actions, side effects, and administration", section on 'Drug interactions'.)
Late gadolinium enhancement to risk stratify patients for primary prevention ICD placement (January 2017)
Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging appears to reflect myocardial fibrosis, which has been proposed as a pathogenic factor for ventricular arrhythmias. Risk stratification remains imperfect for identifying patients at highest risk of sudden cardiac death (SCD) who are most likely to benefit from an implantable cardioverter-defibrillator (ICD).
●A systematic review and meta-analysis of 29 observational studies in patients with nonischemic dilated cardiomyopathy assessed the relationship between LGE on CMR imaging and ventricular arrhythmias, sustained ventricular arrhythmias . Appropriate ICD intervention or sudden cardiac death (SCD) was significantly more likely in patients with LGE, with subgroup analysis revealing that LGE risk stratified patients at all levels of left ventricular ejection fraction (LVEF) (both above and below 35 percent).
●In a meta-analysis, which included 2993 patients with hypertrophic cardiomyopathy from five cohorts, the presence of LGE on CMR imaging was associated with greater risk for total mortality, cardiovascular mortality, and SCD .
While not currently utilized in SCD risk stratification schemes , when the risk of SCD remains uncertain after assessment with conventional risk factors, LGE may help to guide decision-making with regard to implantation of a defibrillator for primary prevention of SCD. (See "Primary prevention of sudden cardiac death in heart failure and cardiomyopathy", section on 'Myocardial fibrosis on CMR' and "Hypertrophic cardiomyopathy: Assessment and management of ventricular arrhythmias and sudden cardiac death risk", section on 'Possible high-risk features'.)
Comparison of complications and efficacy between subcutaneous and transvenous ICDs (December 2016)
Transvenous implantable cardioverter-defibrillators (TV-ICDs) are associated with several complications related to the reliance on endovascular leads. The subcutaneous ICD (S-ICD) was developed to minimize some of the limitations of TV-ICD systems by avoiding endovascular access entirely. In a retrospective cohort study which propensity-matched S-ICD and TV-ICD recipients, the overall complication rate and efficacy was similar between the two groups . S-ICD recipients experienced fewer lead-related complications but more nonlead-related complications, with a similar frequency of ICD shocks (both appropriate and inappropriate) between the two groups. While there are no defined guidelines for the selection of S-ICD over a TV-ICD system, our approach in deciding between the two for a specific patient is based on several clinical variables (algorithm 1). (See "Subcutaneous implantable cardioverter defibrillators", section on 'Comparison with TV-ICD'.)
ICDs for primary prevention of sudden cardiac death in nonischemic cardiomyopathy (September 2016)
Earlier studies, performed before use of cardiac resynchronization therapy (CRT) and current optimal medical therapy, have shown that implantable cardioverter-defibrillator (ICD) therapy reduced total mortality and sudden cardiac death (SCD) in patients with heart failure and nonischemic cardiomyopathy. A new trial (DANISH) in patients with symptomatic nonischemic systolic heart failure (LVEF ≤35 percent) treated with optimal medical therapy (including CRT in the majority of patients) found no reduction in the primary endpoint of total mortality for patients randomized to receive an ICD, compared with no ICD therapy . There was, however, a reduction in SCD, a pre-specified secondary outcome. Thus, although SCD is decreased, ICD therapy for this population does not appear to have an overall total mortality benefit in the setting of guideline-directed optimal medical therapy and cardiac resynchronization therapy. (See "Primary prevention of sudden cardiac death in heart failure and cardiomyopathy", section on 'DANISH trial'.)
CONGENITAL HEART DISEASE, ADULT
Risk factors for mortality in Eisenmenger syndrome (December 2016)
Eisenmenger syndrome consists of the triad of congenital systemic-to-pulmonary cardiovascular communication, pulmonary arterial disease caused by increased pulmonary blood flow, and cyanosis. This syndrome is associated with high mortality rates but limited data are available on predictors of death in a contemporary population. In a multicenter study of 1098 patients with Eisenmenger syndrome followed for a median of three years, significant predictors of death on multivariable analysis included older age, presence of a pre-tricuspid shunt, lower oxygen saturation at rest, lack of sinus rhythm, and presence of pericardial effusion . (See "Evaluation and prognosis of Eisenmenger syndrome", section on 'Prognosis'.)
CORONARY ARTERY BYPASS GRAFT SURGERY
Multiple rather than single arterial grafts in patients undergoing CABG (December 2016)
There is conflicting evidence as to whether survival is improved with placement of multiple arterial grafts, rather than one, in patients undergoing coronary artery bypass graft surgery (CABG). The 2016 ART trial, which randomly assigned 3102 patients scheduled to undergo CABG to bilateral or single internal thoracic artery grafting, found no significant difference in the rate of death at five years. . Based on findings from earlier studies, and the relatively short-term follow-up of the ART trial, we consider placing multiple arterial grafts in patients with a predicted longevity of more than 10 years who are not at high risk of sternal wound infection (which occurs more frequently with multiple arterial grafts). (See "Coronary artery bypass graft surgery: Long-term clinical outcomes", section on 'Multiple arterial grafts'.)
M. chimaera infections associated with cardiac surgery (October 2016)
Clusters of disseminated infection with Mycobacterium chimaera in the United States, Europe, and elsewhere have been linked to exposure to contaminated Stockert 3T heater-cooler devices during cardiac surgery . In the United States, the Food and Drug Administration recommends retiring 3T heater-cooler devices and accessories that have tested positive for M. chimaera or that have been linked to known infections and refraining from using any 3T heater-cooler device manufactured before September 2014 except in emergency situations. Providers of patients who have undergone cardiac surgery should be aware of the possibility of M. chimaera infection, even months to years following the procedure. (See "Overview of nontuberculous mycobacterial infections in HIV-negative patients", section on 'Disseminated disease'.)
CORONARY HEART DISEASE, ACUTE
Switching MI patients from ticagrelor to clopidogrel (March 2017)
The potent platelet P2Y12 receptor blocker ticagrelor, rather than clopidogrel, is initiated in hospital for many patients with myocardial infarction. However, some of these individuals will need to switch to clopidogrel either before or after hospital discharge. A randomized trial compared the pharmacodynamic effects of switching from ticagrelor to clopidogrel with or without a loading dose of clopidogrel . The study identified a period of time after the first dose of clopidogrel (12 hours after the last dose of ticagrelor) when there was greater antiplatelet effect with the loading dose than without. Based on this pharmacodynamic study, we give a clopidogrel loading dose of 600 mg when switching from ticagrelor to clopidogrel therapy. (See "Antiplatelet agents in acute ST elevation myocardial infarction", section on 'Switching from a P2Y12 agent to clopidogrel' and "Antiplatelet agents in acute non-ST elevation acute coronary syndromes", section on 'Switching from a P2Y12 agent to clopidogrel'.)
Complete revascularization for STEMI patients undergoing primary PCI (February 2017)
For patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI), the optimal management of significant non-culprit lesions is not known. A 2017 network meta-analysis compared four revascularization strategies: complete revascularization at the index procedure; complete revascularization prior to discharge; complete revascularization within a few weeks after discharge; and culprit-only PCI . Major adverse cardiovascular events occurred less frequently in patients who underwent complete revascularization, performed at any of the time intervals, compared with culprit-only PCI. The outcome was mainly attributable to a lower rate of urgent revascularization. This meta-analysis supports our suggestion to perform complete revascularization prior to discharge. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Non-culprit lesions", section on 'Management approaches to non-culprit lesions'.)
CORONARY HEART DISEASE, STABLE
Rivaroxaban plus P2Y12 inhibitor in patients with atrial fibrillation who undergo coronary stenting (March 2017)
The optimal antithrombotic regimen for patients with atrial fibrillation (AF) who undergo coronary artery stenting is not known. Patients may require a period of triple antithrombotic therapy with an oral anticoagulant, aspirin, and a P2Y12 inhibitor (usually clopidogrel). In most of the studies that have evaluated triple therapy, warfarin was the anticoagulant rather than a non-vitamin K antagonist oral anticoagulant. In addition, bleeding complications have led to the evaluation of antithrombotic therapy with two agents. The PIONEER AF-PCI trial compared three regimens in over 2000 patients: low-dose rivaroxaban plus a P2Y12 inhibitor for 12 months; very-low-dose rivaroxaban plus dual antiplatelet therapy (DAPT); or standard therapy with a dose-adjusted vitamin K antagonist plus DAPT . Clinically significant bleeding occurred less often in the two groups receiving rivaroxaban; efficacy was similar in the three groups at 12 months. This study supports the use of rivaroxaban as a reasonable alternative to warfarin, and the use of two rather than three drugs in patients who are candidates for triple therapy. The very-low-dose of rivaroxaban used in the trial is not approved for use in this setting. (See "Antithrombotic therapy after coronary stenting in patients receiving long-term anticoagulation", section on 'Alternatives to warfarin'.)
J-shaped relationship between blood pressure and cardiovascular outcomes (November 2016)
There may be a blood pressure threshold below which tissue perfusion is reduced and risk is increased for cardiovascular and renal events and mortality (a J-shaped curve between blood pressure and event rate). In a large international prospective observational study of patients with stable coronary artery disease and treated hypertension, achieved diastolic pressures below 70 and above 80 mmHg were independently associated with increased risk for adverse outcomes (figure 1) . Similarly, achieved systolic pressures below 120 and above 140 mmHg were independently associated with increased risk for adverse outcomes (figure 2). However, these data are observational, and other evidence disputes the importance of these J-shaped curves, particularly for systolic pressure. Based upon the available evidence and the physiology of coronary perfusion, we generally try to avoid lowering the diastolic blood pressure to a value of <60 mmHg in most patients. (See "What is goal blood pressure in the treatment of hypertension?", section on 'J-shaped diastolic curve'.)
Targeting natriuretic peptide level in treatment of acute heart failure (February 2017)
Since natriuretic peptides have relatively short half-lives, it has been postulated that serial measurements might help guide management of acute heart failure. A systematic review found low-quality evidence supporting an association between achievement of natriuretic predischarge thresholds and reduced acute heart failure mortality and readmission . However, a randomized trial studying the effect of treating to a target natriuretic peptide level found no improvement in outcomes with a natriuretic peptide-guided strategy, although a reduction in natriuretic peptide during hospitalization was associated with better outcomes [17,18]. Thus, natriuretic peptide levels have prognostic value in patients with acute heart failure, but evidence does not support targeting lower levels as a means of improving outcomes. (See "Natriuretic peptide measurement in heart failure", section on 'Acute HF'.)
Fully magnetically levitated centrifugal pump for advanced heart failure (November 2016)
Continuous flow left ventricular assist devices improve survival in selected patients with refractory heart failure, but these devices are subject to risk of pump thrombosis requiring surgical pump exchange. An unblinded randomized trial compared outcomes in patients receiving either an investigational fully magnetically levitated centrifugal pump, designed to reduce shear stress and thus avoid pump thrombosis, to a commercially available axial pump . Rates of mortality and of stroke were similar in the two treatment groups, but there was a lower rate of reoperation for pump malfunction due to absence of confirmed pump thrombosis in the investigational pump group. (See "Intermediate- and long-term mechanical circulatory support", section on 'Heartmate 3'.)
Risk of thromboembolism in patients with HCM and LV apical aneurysm (February 2017)
Although subsets of patients with hypertrophic cardiomyopathy (HCM) and a risk factor for thromboembolism (eg, atrial fibrillation, left ventricular [LV] aneurysm) are at high risk for thromboembolic events, they have generally been excluded from studies of thromboembolism prophylaxis. Among a cohort of patients with HCM and LV apical aneurysm who were in normal sinus rhythm, the thromboembolic event rate without anticoagulation exceeded 1 percent per year, regardless of the size of the aneurysm . For patients with HCM and LV apical aneurysm, we suggest long-term oral anticoagulation, rather than aspirin or no anticoagulation, to reduce the risk of thromboembolism. (See "Hypertrophic cardiomyopathy: Medical therapy", section on 'Thromboembolism prophylaxis'.)
Safety and efficacy of anakinra for refractory pericarditis (November 2016)
Nonsteroidal anti-inflammatory drugs and colchicine are the preferred initial therapy for acute pericarditis, with glucocorticoids as second-line treatment. Despite therapy, some patients have persistent or recurrent symptoms. A small preliminary randomized trial in patients with recurrent pericarditis and glucocorticoid dependence compared treatment with anakinra (an interleukin 1-beta recombinant receptor antagonist) or placebo for six months following initial treatment with anakinra for two months in both groups . The group that continued anakinra had fewer recurrences and greater symptom-free survival, although prolonged anakinra use was associated with more frequent side effects (mostly nonlimiting local skin reactions). Larger studies are needed to determine safety and long-term efficacy. (See "Recurrent pericarditis", section on 'Other immune therapy'.)
Cardiotoxicity of checkpoint inhibitor immunotherapy (November 2016)
Checkpoint inhibitor immunotherapy for melanoma and other cancers may result in severe or fatal cardiotoxicity, even in the absence of a history of significant cardiac risk factors . High-dose steroids are indicated to treat myositis and other cardiac complications, but symptoms may progress in some cases despite steroids. The early institution of more aggressive immunosuppressive therapy and monitoring should be considered for patients without an immediate response to high-dose steroids. (See "Toxicities associated with checkpoint inhibitor immunotherapy", section on 'Cardiotoxicity'.)
PERIPHERAL VASCULAR DISEASE
Ticagrelor versus clopidogrel for prevention of cardiovascular events in patients with peripheral artery disease (January 2017)
Antiplatelet therapy is recommended for patients with peripheral artery disease (PAD) to prevent future cardiovascular events. The EUCLID trial randomly assigned nearly 14,000 patients with symptomatic PAD to ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily . The clopidogrel group had less ischemic stroke (1.9 versus 2.4 percent), but there were no significant differences between groups for the composite primary outcome (cardiovascular death, myocardial infarction [MI], or ischemic stroke) or for death, MI, acute limb ischemia, need for revascularization, or major bleeding. Patients receiving ticagrelor were more likely to discontinue treatment due to dyspnea or minor bleeding. These data support the use of clopidogrel rather than ticagrelor as an alternative to aspirin for patients with PAD. (See "Overview of lower extremity peripheral artery disease", section on 'Antithrombotic therapy'.)
ACE inhibitors or ARBs not routinely indicated in low-risk patients with stable ischemic heart disease (January 2017)
Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin receptor blockers (ARBs), referred to as renin angiotensin system inhibitors (RASi), improve survival in high-risk patients with stable ischemic heart disease (SIHD), such as those with heart failure or diabetes. However, a 2017 meta-analysis of 24 randomized trials of RASi compared with placebo or to active control in patients with SIHD without clinical heart failure and with a left ventricular ejection fraction ≥40 percent found that benefit was not present in patients enrolled in studies in which the cardiovascular event rates were low . We do not routinely prescribe RASi to patients with SIHD at low risk of adverse cardiovascular events. (See "Prevention of cardiovascular disease events in those with established disease or at high risk", section on 'ACE inhibitors or ARBs'.)
Role of troponin testing in primary prevention (January 2017)
Across a broad range of populations, elevated troponin is associated with an increased risk of cardiovascular disease (CVD) events. In the primary prevention West of Scotland Coronary Prevention Study of individuals at high CVD risk who were randomly assigned to either statin or placebo, individuals in the highest quartile of high-sensitivity troponin were at the greatest risk of a CVD event at one year in both treated and untreated individuals . Studies designed to evaluate the role of troponin testing in patients being considered for statin therapy or in those started on statin therapy are ongoing. (See "Elevated cardiac troponin concentration in the absence of an acute coronary syndrome", section on 'Elevations in patients at high risk'.)
Risk calculator for estimating cardiovascular disease risk in Chinese patients (January 2017)
A number of multivariate risk models have been developed for estimating the risk of initial cardiovascular disease (CVD) events in apparently healthy, asymptomatic individuals. The Predication for ASCVD Risk in China (China-PAR) project published a risk score which was developed and prospectively validated in two Chinese cohort groups . China-PAR, the first risk estimator specific to Chinese populations, more accurately predicted the risk of future CVD events for Chinese patients than the ACC/AHA pooled cohort equations, which were developed and validated in North American populations. While all risk models have advantages and disadvantages and no single risk model is appropriate for all patients, clinicians should choose a risk calculator which is most appropriate based on the gender and ethnicity of the patient. (See "Estimation of cardiovascular risk in an individual patient without known cardiovascular disease", section on 'China-PAR risk predictor (2016)'.)
Inhibitors of PCSK9 synthesis (December 2016)
The profound ability of monoclonal antibodies to proprotein convertase subtilisin/kexin type 9 (PCSK9) to lower low density lipoprotein-cholesterol (LDL-C) has prompted research into other ways of lowering PCSK9. Small interfering RNA molecules (siRNA) offer the potential to lower PCSK9 and require a lower dose frequency than monoclonal antibodies. One siRNA inhibitor of PCSK9 synthesis has undergone phase 1 evaluation . In that trial, 24 patients were randomly assigned to a subcutaneous inclisiran, a long-acting RNA interference therapeutic agent, or placebo. Inclisiran reduced LDL-C without serious adverse events. (See "PCSK9 inhibitors: Pharmacology, adverse effects, and use", section on 'Current investigation'.)
Inadequate sleep and adverse cardiometabolic outcomes (December 2016)
The adverse health outcomes of inadequate sleep duration (<7 hours per night) and quality are increasingly recognized. A new scientific statement from the American Heart Association reviews data linking sleep restriction with adverse cardiometabolic outcomes and recommends that healthy sleep behavior be addressed in public health campaigns to promote ideal cardiac health, alongside blood pressure, cholesterol, diet, blood glucose, physical activity, weight, and smoking cessation . (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Cardiovascular morbidity'.)
CABG versus PCI for significant left main coronary artery disease (November 2016)
Most patients with significant left main coronary artery disease (LMCAD) are referred for revascularization, generally with coronary artery bypass graft surgery (CABG) rather than percutaneous coronary intervention (PCI) with drug eluting stents (DES). The EXCEL and NOBLE trials compared CABG and PCI with current generation DES in patients with LMCAD and low or intermediate disease complexity [28,29]. At long-term follow-up, CABG and PCI appear to have similar rates of death from any cause or myocardial infarction, while the rate of revascularization was higher with PCI. PCI may be an acceptable option for some patients with lower complexity left main coronary disease who can undergo PCI at a reasonable risk. (See "Management of left main coronary artery disease", section on 'Randomized trials'.)
VALVULAR HEART DISEASE
Transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate risk patients (March 2017)
The role of transcatheter aortic valve implantation (TAVI) in patients with symptomatic severe aortic stenosis with intermediate surgical risk has not been established. A randomized trial in over 1700 patients compared outcomes following TAVI (with a self-expanding bioprosthesis; over 90 percent via transfemoral access) versus surgical aortic valve placement (SAVR) . The incidence of the primary composite end point of death from any cause or disabling stroke at 24 months was similar in the two groups. Rates of atrial fibrillation, transfusion, and acute kidney injury were more frequent in the SAVR group, while major vascular complications, permanent pacemaker implantation, and paravalvular aortic regurgitation were more common in the TAVI group. These results add to prior randomized controlled trials in showing that transfemoral TAVI is a noninferior alternative to SAVR in intermediate surgical risk patients with symptomatic severe aortic stenosis. (See "Choice of therapy for symptomatic severe aortic stenosis", section on 'In intermediate-risk patients'.)
Cerebral protection device for transcatheter aortic valve implantation (December 2016)
Transcatheter aortic valve implantation (TAVI) has an evolving role as an alternative to surgical aortic valve replacement in treating patients with symptomatic severe aortic stenosis. However, TAVI is associated with risk of stroke and increased risk of subclinical ischemic brain lesions on magnetic resonance imaging (MRI). Cerebral protection devices have been studied as potential means of reducing this risk of stroke. The Sentinel transcatheter cerebral embolic protection device consists of two filters, which are positioned in the brachiocephalic and left common carotid arteries before TAVI and are removed after TAVI. A meta-analysis of three randomized controlled trials of the Sentinel device found that it reduced the total new lesion volume in protected brain regions on MRI . In the largest included trial (with 363 patients), no significant effect on stroke rates or new lesion volume was found . However, the trial was underpowered and the device was designed to protect only limited brain regions (given the dual blood supply of the posterior circulation). Further study is required to assess the clinical effectiveness of a cerebral protection device for TAVI. (See "Transcatheter aortic valve implantation: Complications", section on 'Stroke and subclinical brain injury'.)
Treatment options for symptomatic severe aortic stenosis with intermediate surgical risk (November 2016)
A meta-analysis of four randomized trials with over 3000 patients with symptomatic severe aortic stenosis (AS) at predominantly intermediate risk of perioperative death compared outcomes at two years for transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR) . Transfemoral TAVI, but not alternative access (non-transfemoral) TAVI, reduced mortality compared with SAVR. TAVI compared with SAVR increased the risk for worsened heart failure symptoms, permanent pacemaker insertion, and moderate or severe aortic valve regurgitation. For patients with symptomatic severe AS and intermediate surgical risk, the Heart Valve Team should perform an individualized risk-benefit assessment of transfemoral TAVI versus SAVR if transfemoral TAVI is feasible; if transfemoral TAVI is not feasible, we recommend SAVR. (See "Choice of therapy for symptomatic severe aortic stenosis", section on 'In intermediate-risk patients'.)
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