ImportanceIn patients with severe aortic valve stenosis at intermediate surgical risk, transcatheter aortic valve replacement (TAVR) with a self-expanding supra-annular valve was noninferior to surgery for all-cause mortality or disabling stroke at 2 years. Comparisons of longer-term clinical and hemodynamic outcomes in these patients are limited.ObjectiveTo report prespecified secondary 5-year outcomes from the Symptomatic Aortic Stenosis in Intermediate Risk Subjects Who Need Aortic Valve Replacement (SURTAVI) randomized clinical trial.Design, Setting, and ParticipantsSURTAVI is a prospective randomized, unblinded clinical trial. Randomization was stratified by investigational site and need for revascularization determined by the local heart teams. Patients with severe aortic valve stenosis deemed to be at intermediate risk of 30-day surgical mortality were enrolled at 87 centers from June 19, 2012, to June 30, 2016, in Europe and North America. Analysis took place between August and October 2021.InterventionPatients were randomized to TAVR with a self-expanding, supra-annular transcatheter or a surgical bioprosthesis.Main Outcomes and MeasuresThe prespecified secondary end points of death or disabling stroke and other adverse events and hemodynamic findings at 5 years. An independent clinical event committee adjudicated all serious adverse events and an independent echocardiographic core laboratory evaluated all echocardiograms at 5 years.ResultsA total of 1660 individuals underwent an attempted TAVR (n = 864) or surgical (n = 796) procedure. The mean (SD) age was 79.8 (6.2) years, 724 (43.6%) were female, and the mean (SD) Society of Thoracic Surgery Predicted Risk of Mortality score was 4.5% (1.6%). At 5 years, the rates of death or disabling stroke were similar (TAVR, 31.3% vs surgery, 30.8%; hazard ratio, 1.02 [95% CI, 0.85-1.22]; P = .85). Transprosthetic gradients remained lower (mean [SD], 8.6 [5.5] mm Hg vs 11.2 [6.0] mm Hg; P < .001) and aortic valve areas were higher (mean [SD], 2.2 [0.7] cm2 vs 1.8 [0.6] cm2; P < .001) with TAVR vs surgery. More patients had moderate/severe paravalvular leak with TAVR than surgery (11 [3.0%] vs 2 [0.7%]; risk difference, 2.37% [95% CI, 0.17%- 4.85%]; P = .05). New pacemaker implantation rates were higher for TAVR than surgery at 5 years (289 [39.1%] vs 94 [15.1%]; hazard ratio, 3.30 [95% CI, 2.61-4.17]; log-rank P < .001), as were valve reintervention rates (27 [3.5%] vs 11 [1.9%]; hazard ratio, 2.21 [95% CI, 1.10-4.45]; log-rank P = .02), although between 2 and 5 years only 6 patients who underwent TAVR and 7 who underwent surgery required a reintervention.Conclusions and RelevanceAmong intermediate-risk patients with symptomatic severe aortic stenosis, major clinical outcomes at 5 years were similar for TAVR and surgery. TAVR was associated with superior hemodynamic valve performance but also with more paravalvular leak and valve reinterventions.

Tolstoy’s writings were clearly important to Wittgenstein. He carried Tolstoy’s The Gospel in Brief with him during the war, and he said that it ‘virtually kept [him] alive’. But commentators have hesitated to extend Tolstoy’s influence to Wittgenstein’s philosophy. This essay argues that there are important parallels in structure and content between Tolstoy’s A Confession and Wittgenstein’s Tractatus which suggest Tolstoy’s influence and which help us to see how we should understand the Tractatus. By comparing these two works we can see more clearly in the Tractatus the idea that the solution to philosophical problems lies in their disappearance and that the structure and content of the Tractatus are expressions of that conception.

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Patrick J. Deneen has written a jeremiad on the state of American higher education and, more particularly, on the fate of the traditional liberal arts. Like Deneen, I mourn the decline and fall of an intellectual and pedagogic tradition that has been one of the highpoints of Western civilization, but unlike Deneen I see the cause of its decline and the possibility of its recovery in a different way. In this essay, I propose to (1) indicate my general agreement with Deneen's requiem for the sorry state of the traditional liberal arts, and (2) summarize and analyze his argument and show why it is mistaken. In Solidarity with Comrade DeneenPatrick Deneen and I share quite a bit in common in our experiences in higher education and in our assessment of the current state of the liberal arts. Like Deneen, I came to intellectual maturity during the first wave of the academic culture wars of the 1980s. As a graduate student at Brown University, one of America's most liberal and politically correct universities, I saw up close the hypocrisy, dishonesty, intimidation, and sometimes even the violence used by the campus Left to impose its psychological and moral hegemony on campus. I also saw how the liberal arts were corrupted, gutted, and repackaged to serve the ideological interests of the postmodern, multiculturalist Left.

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