What is the recommended management approach for a patient in their late 60s or older with severe aortic stenosis and reduced ejection fraction, Transcatheter Aortic Valve Replacement (TAVR) or Surgical Aortic Valve Replacement (SAVR)?

Management of Severe Aortic Stenosis in Late 60s or Older with Reduced Ejection Fraction

For a patient in their late 60s or older with severe aortic stenosis and reduced ejection fraction, transcatheter aortic valve replacement (TAVR) is the preferred intervention, particularly if the patient is ≥75 years old or has high surgical risk (STS-PROM ≥8%). 1, 2

Age-Based Decision Algorithm

Patients ≥80 Years Old

• TAVR is definitively recommended over surgical aortic valve replacement (SAVR) 1, 2
• This recommendation assumes transfemoral access is anatomically feasible 1
• Meta-analysis of 7 major RCTs demonstrated TAVR reduces 2-year all-cause mortality regardless of STS risk score in this age group 1

Patients 65-80 Years Old

• Either TAVR or SAVR is appropriate, with the decision based on surgical risk stratification 1
• If STS-PROM ≥8% or EuroSCORE II >8%: TAVR is preferred 1, 3
• If STS-PROM 4-8%: Either approach is reasonable after shared decision-making 3
• If STS-PROM <4% with no frailty: SAVR may be considered for superior long-term durability data 3

Critical Factors Favoring TAVR in This Population

Reduced Ejection Fraction Considerations

• TAVR demonstrates superior recovery of left ventricular ejection fraction compared to SAVR in patients with baseline LVEF ≤50% 4
• In a prospective study, 58% of TAVR patients achieved LVEF normalization (>50%) at 1 year versus only 20% in the SAVR group 4
• TAVR avoids the detrimental effects of cardiopulmonary bypass, which is particularly important in patients with compromised ventricular function 5

High-Risk Features That Mandate TAVR

The following conditions strongly favor TAVR over SAVR 1, 3:

• Porcelain aorta or hostile chest anatomy (e.g., prior cardiac surgery, chest radiation) 1, 3
• Moderate-to-severe frailty (even with lower STS scores) 1, 3
• Oxygen-dependent lung disease 1, 3
• Dialysis dependence 1, 3
• Cirrhosis with MELD score >14 1, 3
• Multiple organ system compromise (≥2 major organs) 3

Anatomic Requirements for TAVR

Transfemoral Access Assessment

• Adequate iliofemoral vessel diameter with minimal calcification is required 1, 3
• If transfemoral access is unsuitable and patient is inoperable, non-transfemoral TAVR may be considered but carries higher risk 1
• Aortic root anatomy must be evaluated for excessive calcification or annulus size out of range for available devices 1

Outcomes Data Supporting TAVR in This Population

Mortality Benefit

• TAVR reduces 2-year mortality to 43.3% versus 68.0% with medical therapy in high-risk patients 6
• Cardiac death rates at 2 years: 31.0% with TAVR versus 62.4% with standard therapy 6
• Without intervention, symptomatic severe AS has 50% mortality within 1-2 years 2, 7

Functional Recovery

• TAVR provides sustained improvement in functional status and valve hemodynamics at 2 years 6
• Rehospitalization rates are significantly lower: 35.0% with TAVR versus 72.5% with medical therapy 6
• Larger effective orifice area achieved with TAVR compared to surgical bioprosthetic valves 5

Critical Pitfalls to Avoid

Risk Assessment Errors

• Do not rely solely on STS-PROM score, as it underestimates risk in elderly patients and fails to account for frailty, disability, or cognitive function 3
• Do not ignore frailty assessment: moderate-severe frailty shifts the decision toward TAVR even with lower calculated surgical risk scores 1, 3

Contraindications to Intervention

• Do not proceed with any intervention if life expectancy <1 year due to extensive comorbidities, moderate-to-severe dementia, or end-stage organ disease 1
• Futility criteria: STS-PROM >15% with life expectancy <1 year or poor rehabilitation potential 1

Mandatory Multidisciplinary Evaluation

All decisions must involve a Heart Valve Team including 1, 3:

• Interventional cardiologists
• Cardiac surgeons
• Cardiac imaging specialists
• Anesthesiologists
• Heart failure specialists
• Geriatric assessment when appropriate

The team evaluates surgical risk, frailty, anatomic suitability, patient preferences, and expected longevity versus valve durability 1

Special Consideration: Concomitant Coronary Disease

• If significant coronary disease requires surgical revascularization (CABG), SAVR + CABG is preferred over TAVR 1, 3
• If coronary disease is amenable to percutaneous coronary intervention (PCI), PCI can be performed before TAVR 1
• For complex left main or multivessel disease with SYNTAX score >33, SAVR + CABG is reasonable over TAVR + PCI 1