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Patient values and preferences on valve replacement for aortic stenosis: a systematic review
  1. Anja Fog Heen1,
  2. Lyubov Lytvyn2,
  3. Michael Shapiro3,
  4. Gordon Henry Guyatt2,
  5. Reed Alexander Cunningham Siemieniuk2,
  6. Yuan Zhang2,
  7. Veena Manja4,5,
  8. Per Olav Vandvik6,
  9. Thomas Agoritsas2,7
  1. 1Department of Medicine, Innlandet Hospital Trust Gjøvik Hospital, Brumunddal, Norway
  2. 2Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
  3. 3Chicago, Illinois, USA
  4. 4Department of Surgery, University of California Davis, Sacramento, California, USA
  5. 5Department of Medicine, Veterans Affairs Northern California Health Care System, Mather, California, USA
  6. 6Institute of Health and Society, University of Oslo, Oslo, Norway
  7. 7Division of General Internal Medicine, Department of Medicine, University Hospitals of Geneva, Geneva, Switzerland
  1. Correspondence to Dr Anja Fog Heen, Dept. of Medicine, Innlandet Hospital Trust Gjøvik Hospital, 2819 Gjøvik, Norway; anjaheen{at}


The review aims to summarise evidence addressing patients’ values, preferences and practical issues on deciding between transcatheter aortic valve insertion (TAVI) and surgical aortic valve replacement (SAVR) for aortic stenosis. We searched databases and grey literature until June 2020. We included studies of adults with aortic stenosis eliciting values and preferences about treatment, excluding medical management or palliative care. Qualitative findings were synthesised using thematic analysis, and quantitative findings were narratively described. Evidence certainty was assessed using CERQual (Confidence in the Evidence from Reviews of Qualitative Research) and GRADE (Grading of Recommendations Assessment, Development and Evaluation). We included eight studies. Findings ranged from low to very low certainty. Most studies only addressed TAVI. Studies addressing both TAVI and SAVR reported on factors affecting patients’ decision-making along with treatment effectiveness, instead of trade-offs between procedures. Willingness to accept risk varied considerably. To improve their health status, participants were willing to accept higher mortality risk than current evidence suggests for either procedure. No study explicitly addressed valve reintervention, and one study reported variability in willingness to accept shorter duration of known effectiveness of TAVI compared with SAVR. The most common themes were desire for symptom relief and improved function. Participants preferred minimally invasive procedures with shorter hospital stay and recovery. The current body of evidence on patients’ values, preferences and practical issues related to aortic stenosis management is of suboptimal rigour and reports widely disparate results regarding patients’ perceptions. These findings emphasise the need for higher quality studies to inform clinical practice guidelines and the central importance of shared decision-making to individualise care fitted to each patient.

  • aortic valve stenosis
  • transcatheter aortic valve replacement
  • heart valve prosthesis implantation
  • quality of health care

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  • AFH and LL contributed equally.

  • Contributors AFH led and coordinated the project. TA and POV provided supervision. AFH, LL and TA screened the studies for eligibility. AFH and LL extracted the data, assessed study risk of bias and synthesised the data. AFH, LL and TA assessed the quality of the body of evidence. All study authors were involved in the interpretation and discussion of the results. AFH and LL drafted the manuscript, and all authors critically revised the manuscript. All authors approved the final version of the article. AFH is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AFH, LL, GG, RACS, TA, POV and YZ are members of the GRADE working group. YZ designed the risk of bias tool and the GRADE evaluation for values and preferences studies. There are no other relationships or activities that could appear to have influenced the submitted work.

  • Patient and public involvement statement Outcomes of interest included for this review were established by a multidisciplinary guideline panel that included three patient partners. One patient partner (MMS) from the guideline panel was included as a coauthor of this study. MMS was involved in the interpretation of study results and provided feedback on the manuscript.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.