ABC | Volume 114, Nº2, February 2020

Viewpoint Arq Bras Cardiol. 2020; 114(2):313-318 Lopes et al. Treatment of aortic stenosis in elderly individuals in Brazil Figure 4 – Correlation between the percentage change in mortality rates from non-rheumatic calcific aortic valve disease and the sociodemographic development index (SDI) by Brazilian state in 1990 (A) and 2017 (B). health care technologies; 4) the Brazilian health care system, particularly specialized and medium/high complexity care, as is the case with TAVI, is not evenly distributed throughout the country, and besides, Brazilian hospital structure, diagnostic infrastructure, and clinical staff is not as widely available or efficient as those in European countries, and thus, the rate of diagnosis and procedures performed in the country would not be nearly compatible with European ones; 5) the number of 8,518 procedures/year is very close to the 9,000 procedures/year performed in the United States upon the request for incorporation (with the United States having a much larger population than Brazil), and, as mentioned in the public consultation, is a number incompatible with the epidemiological and health care access characteristics of the Brazilian population. Still regarding the estimate of the number of procedures per year, it is noteworthy that, through a comparative analysis with similar procedures offered by the SUS, it is easily seen that such estimate is at least unrealistic. Table 1 shows, based on official data from the Department of Informatics of the Unified Health System (DATASUS), the number of surgical cardiac valvular procedures performed in Brazil between 2008 and 2018. It is noteworthy that the data provided by DATASUS do not allow the identification of the age of the patients, the valve treated, or the etiology and type of valvular disease. Data related to prosthetic valve implantation include both mitral and aortic implantations. In this DATASUS estimate, the total number of surgeries for prosthetic valve implantation does not exceed 8,518 per year. In 11 years, 88,280 surgeries for prosthetic valve implantation were performed in Brazil considering all age groups and implantations of any heart valve. Additionally, the total number of valvular surgeries, including those associated with myocardial revascularization, multiple valvular replacement, and prosthetic valve implantation, reached a maximum of 11,315 procedures in the year of 2012. Because it is intended for a subgroup of older patients (> 75 years) with aortic stenosis, TAVI would certainly not have been performed with a frequency similar to that of all valvular surgeries performed in the SUS. Also, a large meta-analysis has suggested that 316