• Transcatheter Aortic Valve Replacement
• Delivery of Health Care
• Health Care Economics and Organizations
• Aortic Valve Stenosis
• Heart Valve Prosthesis

In this interesting manuscript, Hibino et al set out to describe mortality in the setting of aortic stenosis (AS) in high-income countries over the last 20 years.1 The last 20 years have seen an epic change in management of aortic valve stenosis with the advent, early adoption and proliferation of interventional percutaneous aortic valve replacement (TAVR) which was initially intended to treat patients with prohibitively high risk for surgical valve replacement.2 With adoption and proliferation of non-surgical TAVR, evidence was generated to show non-inferiority as an alternative strategy to open surgical valve replacement in elderly patients even at lower surgical risk.3 Thus, adoption of the concept of non-surgical aortic valve replacement has expanded the indication for active treatment of AS (in an old and high-risk cohort who would otherwise be palliated), and provided an attractive alternative to surgical valve replacement at least in high-income countries with a sufficiently funded healthcare system to afford the extra cost of TAVR (even for patients with moderate and low risk for surgical repair).4

Based on WHO mortality data the authors found an annual age-standardised mortality rate per 100 000 citizens between 0.93 in Japan and 2.20 in Germany. Over the last decade decreasing mortality trends from AS were seen in countries like Germany (−1.2%), Australia (−1.9%) and in the USA (−3.1%); such decreasing mortality trend was seen in all eight high-income countries in patients over the age of 80 years.

The analysis by Hibino et al is compelling but deserves a closer look in view of the reasons of the observed trend.1 Looking into the data set in a more granular fashion it becomes obvious that a trend of decreasing mortality in the setting with AS could not be demonstrated in the first decade of the analysed timespan (from 2000 …