The VESALIUS-CV trial appeared too late to inform recent multi-society dyslipidemia guidelines, and its findings have already prompted consideration of whether the boundary between primary and secondary prevention no longer holds when an LDL-C goal is being set. If that concession is granted, the harder question is an operational one that remains unanswered: at the bedside, which patient is a VESALIUS-CV patient? Herein we set the primary-secondary distinction aside altogether and offer a practical worksheet for identifying the subjects who merit more aggressive lipid lowering, and access to PCSK9 inhibitors when necessary to reach new and lower LDL-C goals.

Previous articles have comprehensively reported on clinical outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with chronic kidney disease, including dialysis patients. Some studies suggest better short-term outcomes with TAVR, including less periprocedural mortality, acute-on-chronic kidney injury, bleeding, and shorter length of stay, but similar or worse long-term survival compared with SAVR. Although clinical outcomes have been studied, comparative durability and risk of structural valve deterioration (SVD) between transcatheter and surgical bioprosthetic valves in dialysis patients remain poorly defined. The therapeutic approach for the treatment of aortic valve disease in patients with end-stage renal disease is clinically relevant because these patients have short life expectancy and often receive bioprosthetic valves that are at higher risk for accelerated SVD and failure. In this review we synthesize current literature that describes TAVR and SAVR valve durability in patients with end-stage renal disease with a focus on mechanisms of bioprosthetic SVD, and outcomes associated with TAVR and SAVR, and explore strategies for lifelong management of aortic valve disease, including considerations for reintervention.