The recommen- dation for SAVR in preference to TAVI includes asymptomatic patients for whom AVR is being considered because of an abnormal exercise blood pressure response, an elevated serum BNP level, rapid hemodynamic progression, or very severe AS with a velocity of 5 m/s. The final choice of implantation approach is based on a shared decision-making process that accounts for the patient s values and preferences and includes discussion of the indications for and against each approach and the potential need for and risks associated with valve reintervention.30 32 6. Published RCTs have focused primarily on TAVI via the transfemoral vascular access route. The mortality rate has been higher with TAVI by nonfemoral access routes than with SAVR, possibly because of the access approach itself, but more likely because of the higher comor- bidity burden and risk in patients with vascular disease severe enough to preclude transfemo- ral access. When transfemoral TAVI is not fea- sible, SAVR or palliative care options should be included in the shared decision-making discus- sion. The final choice of implantation approach is based on a shared decision-making process that accounts for the patient s values and pref- erences and includes discussion of the indica- tions for and against each approach and the potential need for and risks associated with 7. TAVI was compared with standard medical therapy in a prospective RCT of patients with severe symptomatic AS who were deemed inop- The rate of all-cause death at 2 years was lower with TAVI (43.3%) (HR: 0.58; medical therapy (68%).12,14,34 Standard therapy included percutaneous aortic balloon dilation in 84%. There was a reduction in repeat hospital- ization with TAVI (55% versus 72.5%; P<0.001). 