How is the decision made between Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (SAVR) in a 72-year-old patient with severe aortic stenosis (AS) based on the Coronary Angiography (CAG) report?

Decision-Making Between TAVR and SAVR in a 72-Year-Old with Severe AS Based on CAG Report

For a 72-year-old patient with severe aortic stenosis, the coronary angiography report primarily determines whether concomitant coronary revascularization is needed, which would favor SAVR, while the primary decision between TAVR and SAVR is driven by surgical risk assessment (STS-PROM score), frailty status, and anatomic suitability for transfemoral access. 1

Role of Coronary Angiography in the Decision

The CAG report influences the TAVR vs. SAVR decision through these specific findings:

• If significant coronary artery disease requiring surgical revascularization (CABG) is present, SAVR is indicated as it allows concurrent CABG during the same operation 1
• If coronary disease is absent or amenable to percutaneous coronary intervention (PCI), proceed with risk-based algorithm below 1
• If severe coronary calcification or complex anatomy makes PCI high-risk, this favors SAVR for combined valve replacement and CABG 1

Primary Decision Algorithm Based on Surgical Risk

Step 1: Calculate STS-PROM Score and Assess Frailty

Low Surgical Risk (STS-PROM <4%, no frailty, no major comorbidities):

• SAVR is recommended due to superior long-term valve durability data and the patient's age of 72 years with expected life expectancy >10-20 years 1
• SAVR is particularly preferred if the patient is <65 years or has life expectancy >20 years, though at 72 this is borderline 1

Intermediate Risk (STS-PROM 4-8%, mild frailty, or 1 major organ compromise):

• Either TAVR or SAVR is appropriate after shared decision-making about valve durability versus procedural recovery 1
• For patients aged 65-80 years (which includes this 72-year-old), both procedures are Class I recommendations if no anatomic contraindication to transfemoral TAVR exists 1
• TAVR is favored if transfemoral access is suitable and patient prefers faster recovery 1

High Risk (STS-PROM >8%, moderate-severe frailty, or ≥2 major organ compromises):

• TAVR is recommended as the preferred approach if transfemoral access is anatomically feasible 1
• SAVR remains an option if TAVR anatomy is unfavorable (excessive annular calcification, annulus size out of range, inadequate vascular access) 1

Step 2: Assess Anatomic Suitability for TAVR

Proceed with TAVR if:

• Transfemoral access is feasible with adequate iliofemoral vessel diameter and minimal calcification 1, 2
• Aortic annulus size is within device range (typically 18-29mm depending on valve type) 1
• Absence of severe annular or left ventricular outflow tract calcification that would prevent proper valve seating 1

Favor SAVR if:

• Porcelain aorta or hostile chest from prior radiation 1
• Aortic root anatomy unfavorable for TAVR (excessive calcification, annulus size out of acceptable range) 1
• Need for other cardiac surgery (ascending aorta replacement, other valve surgery) 1
• Small aortic annulus requiring prosthesis <21mm where surgical options may provide better hemodynamics 1

Step 3: Consider Patient-Specific Factors

Factors favoring TAVR:

• Patient preference for minimally invasive approach with faster recovery 1
• Oxygen-dependent lung disease 1
• Dialysis dependence 1
• Cirrhosis with MELD score >14 1
• Prior cardiac surgery with hostile mediastinum 1

Factors favoring SAVR:

• Patient age 72 with expected longevity >15 years and desire for maximum valve durability 1
• Bicuspid aortic valve (though this is increasingly being treated with TAVR in experienced centers) 1
• Desire for mechanical valve to avoid future reintervention 1

Critical Pitfalls to Avoid

• Do not rely solely on STS-PROM score - it underestimates risk in elderly patients and does not account for frailty, disability, or cognitive function 1
• Do not ignore frailty assessment - moderate-severe frailty shifts decision toward TAVR even with lower STS scores 1
• Do not proceed with TAVR if predicted survival <12 months or chance of survival with benefit at 2 years <25% - palliative care is more appropriate 1, 2
• Do not overlook procedure-specific impediments such as severe peripheral vascular disease that would make transfemoral TAVR high-risk 1
• Recognize that recent data show potential "catch-up" mortality with TAVR in low-risk patients between years 1-2, with increased valve thrombosis rates (2.6% vs 0.7% for SAVR) 1

Mandatory Heart Valve Team Evaluation

All decisions must involve multidisciplinary Heart Valve Team including interventional cardiologists, cardiac surgeons, imaging specialists, anesthesiologists, and heart failure specialists 1, 2. The team must:

• Review complete clinical data including CAG findings 1
• Assess technical feasibility of both procedures 1
• Discuss risks, benefits, and patient values through shared decision-making 1
• Consider local institutional expertise and outcomes data 1

Specific Algorithm for This 72-Year-Old Patient

1. Review CAG for significant CAD requiring CABG → If yes, choose SAVR 1
2. If no CABG needed, calculate STS-PROM and assess frailty 1
3. If STS <4% and no frailty → Choose SAVR for durability 1
4. If STS 4-8% or mild frailty → Assess transfemoral anatomy; if suitable, offer both options with shared decision-making favoring patient preference 1
5. If STS >8% or moderate-severe frailty → Choose TAVR if transfemoral access suitable 1
6. If TAVR anatomy unsuitable at any risk level → Choose SAVR 1