TAVR for Severe Aortic Stenosis
TAVR is the definitive treatment for patients with severe symptomatic aortic stenosis who have prohibitive surgical risk (≥50% mortality or irreversible morbidity at 30 days) and predicted survival >12 months, and represents a reasonable alternative to surgical AVR in high-risk patients (STS score ≥8%). 1
Risk Stratification Framework
Prohibitive Surgical Risk (TAVR Strongly Recommended - Class I):
- Predicted 30-day mortality or major morbidity ≥50% 1
- Disease affecting ≥3 major organ systems unlikely to improve postoperatively 1
- Anatomic contraindications: porcelain aorta, prior chest radiation, arterial bypass graft adherent to chest wall 1
- Severe frailty, severe hepatic disease, or severe pulmonary disease 1
High Surgical Risk (TAVR Reasonable Alternative - Class IIa):
- STS score ≥8% (originally ≥10% in PARTNER trial, revised to ≥8%) 1
- Documented surgical risk ≥15% by two independent cardiac surgeons 1
- Significant anatomic factors increasing surgical complexity 1
Mandatory Prerequisites
Anatomic Requirements:
- Suitable aortic and vascular anatomy for transcatheter access 2, 3
- Trileaflet aortic valve with severe calcific stenosis (bicuspid valves explicitly excluded from routine use) 4
- Appropriate aortic annulus size for available valve platforms 1
Clinical Requirements:
- Predicted post-TAVR survival >12 months 1, 2
- Symptomatic severe AS (any symptoms attributable to AS) 2, 3
- Absence of comorbidities that would preclude expected benefit from AS correction 1
Heart Valve Team Evaluation (Mandatory)
TAVR requires multidisciplinary Heart Valve Team assessment before proceeding - this is not optional but foundational to appropriate patient selection. 1, 2
Core Team Members:
- Interventional cardiologist (assesses transcatheter feasibility, vascular access) 1
- Cardiac surgeon (provides realistic surgical risk estimate, identifies anatomic contraindications) 1
- Imaging specialist (evaluates valve anatomy, annulus size, coronary ostial distance) 1
- Heart failure specialist or VHD expert (provides continuity and integration) 1
Expected Outcomes vs. Surgical AVR
Mortality:
- TAVR: 3-5% at 30 days, 43.3% at 2 years in prohibitive-risk patients 1
- Comparable to surgical AVR in high-risk patients (non-inferior at 1 and 2 years) 1
Stroke Risk (Critical Caveat):
- TAVR: 5-7% at 30 days, 13.8% at 2 years 1
- Higher than medical therapy (5.5% at 2 years) and surgical AVR (2%) 1
- This increased stroke risk must be explicitly discussed with patients 1
TAVR-Specific Complications:
- Vascular access complications: 17% (vs. 1% with surgery) 1
- Permanent pacemaker requirement: 2-9% (Sapien valve) to 19-43% (CoreValve) 1
- Paravalvular aortic regurgitation (device-specific) 1
- Acute kidney injury, coronary occlusion, valve embolization, aortic rupture (rare) 1
Symptom and Quality of Life Benefits
TAVR provides substantial symptomatic improvement in appropriate candidates:
- 75% of TAVR survivors in NYHA class I-II at 1 year (vs. 42% with medical therapy) 1
- 55% reduction in repeat hospitalizations vs. medical therapy 1
- 42% relative mortality reduction at 2 years vs. medical therapy (HR 0.58) 1
When TAVR Should NOT Be Performed
Absolute Contraindications:
- Bicuspid aortic valve (insufficient data, not proven safe) 4
- Acceptable/low surgical risk in younger patients (surgical AVR preferred for durability) 4
- Comorbidities precluding expected benefit from AS correction 1
- Predicted survival <12 months 1, 2
Alternative: Balloon Aortic Valvuloplasty
Consider only as bridge to definitive therapy (Class IIb):
- Temporary palliation in severely symptomatic patients awaiting TAVR or surgical AVR 1
- High restenosis rate and hemodynamic instability risk 1
- Not a definitive treatment strategy 1
Critical Procedural Considerations
TAVR is complex technology requiring meticulous attention: