The Importance of Being Honest

Jack Worthing was absolutely honest when he confessed that he had been found as an infant in a handbag, prompting Lady Bracknell to repeat in disbelief “A handbag?,” and rendering this dialogue one of the most famous scenes in theater ever written. And although the Lady considered this place of breeding “to display a contempt for the ordinary decencies of family life that reminds one of the worst excesses of the French Revolution,” everything turned out well in the end, because Jack had, after all, been honest.[1]

In this issue, the Basle group reports very honest 1-year results with the JenaValve transcatheter aortic valve implantation (TAVI) device using the transapical approach.[2] They treated 28 high-risk patients with a mean age of 80 years over a time span of 1 year. Thirty-day mortality was 14% and all-cause mortality after 1 year 21%. In conclusion, we then read about a “convincing midterm performance of the prosthesis.”

This argumentation may look surprising at first glance. Is a one-fifth mortality for aortic valve implantation in the 21st century deemed a satisfactory result? Yes it is, if those patients are treated for whom the transcatheter techniques were developed. This shift in the risk-profile perspective for cardiac procedures entails a serious prognostic problem, however: will we ever get “true” long-term results—or do we have to assume that all patients simply must be dead after 10 to 15 years? In theory, they should be.

Is it therefore ethical to design studies for implantation of these devices in lower-risk and younger (?!) patients at this point in time? What can we really tell them about the longevity of the TAVI valves as compared with conventional bioprostheses which should have an average life span of 10 years or more? To make matters even more complicated, new products seem to be developed faster than on the mobile-phone market. Even when a valve still bears a familiar brand name in 2015, it is most probably not the original device introduced a few years ago. Where does that leave valid comparisons?

It may be wise to collect as many data as possible before venturing out into unknown country. With the German Aortic Valve Registry (GARY) looking forward to include 100,000 patients and its 5-year follow-up design, a wealth of reliable information is to be expected year after year. Sound and honest arguing rather than hypermotivated activism has always proven its worth in medicine. To express it with the words of Lady Bracknell once more: “To lose one parent, Mr. Worthing, may be regarded as a misfortune; to lose both looks like carelessness.”[1]

• References

• 1 Wilde O. The Importance of Being Earnest: A Trivial Comedy for Serious People. London; St James's Theatre; premiered February 14, 1895.
• 2 Reuthebuch O, Koechlin L, Kaufmann BA, Kessel-Schaefer A, Gahl B, Eckstein FS. Transapical transcatheter aortic valve implantation using the JenaValve: a one-year follow-up. Thorac Cardiovasc Surg 2015; 63 (6) 493-500