The Simplified Age-Based Algorithm is Incorrect and Potentially Harmful
The statement "≥65 → TAVR" is fundamentally wrong according to current ACC/AHA guidelines, which recommend SAVR for patients <65 years with life expectancy >20 years, and only recommend TAVR as preferred for patients >80 years or those with life expectancy <10 years. 1
The Correct Age-Based Framework
Patients <65 Years Old
- SAVR is the Class I recommendation for all patients <65 years with any indication for AVR, regardless of surgical risk 1
- This recommendation exists because there is no evidence base for TAVR in this age group—RCTs included very few patients <65 years, making extrapolation inappropriate 1
- Recent real-world data from California shows TAVR in patients ≤60 years is associated with 2.5-fold increased hazard of 5-year mortality compared to SAVR (HR 2.5,95% CI 1.1-3.7, p=0.02) 2
- Valve durability is critical in younger patients who have longer life expectancy than proven TAVR durability data (currently only ~5 years of robust data) 1
Patients 65-80 Years Old
- Either SAVR or TAVR is appropriate (Class I for both) after shared decision-making about the balance between patient longevity and valve durability 1
- The decision should incorporate surgical risk assessment, anatomic suitability for transfemoral access, frailty, and patient preferences 1
- European guidelines differ slightly, recommending SAVR for patients <75 years with STS-PROM/EuroSCORE <4% 1
Patients >80 Years Old
- TAVR is preferred over SAVR (Class I) if transfemoral access is anatomically feasible 1, 3
- This also applies to younger patients with life expectancy <10 years 1
The Critical Role of Surgical Risk Beyond Age
Age alone is insufficient for decision-making. Surgical risk stratification fundamentally alters the algorithm at any age 1, 3, 4:
High or Prohibitive Surgical Risk (STS-PROM >8%)
- TAVR is recommended regardless of age if post-TAVR survival is expected >12 months with acceptable quality of life 1, 3, 4
- High-risk features include: moderate-to-severe frailty, oxygen-dependent lung disease, dialysis dependence, cirrhosis with MELD >14, porcelain aorta, hostile chest anatomy, or ≥2 major organ system compromise 1, 3, 4
Low Surgical Risk (STS-PROM <4%)
Intermediate Risk (STS-PROM 4-8%)
- Either approach is reasonable with shared decision-making 4
Anatomic Contraindications That Override Age
Certain anatomic factors mandate SAVR regardless of age 1:
- Concomitant severe coronary disease requiring surgical revascularization (CABG) 3, 4
- Other valve pathology requiring surgical intervention 1
- Aortic root anatomy unfavorable for TAVR (excessive calcification, annulus size out of range for available devices) 1
- Inability to achieve transfemoral access 1
Common Pitfalls to Avoid
Do not use age as the sole determinant—this oversimplification ignores surgical risk, frailty, anatomic suitability, and valve durability considerations that are equally or more important 1, 4
Do not rely solely on STS-PROM score—it underestimates risk in elderly patients and fails to account for frailty, disability, or cognitive function 4
Do not ignore frailty assessment—moderate-to-severe frailty shifts the decision toward TAVR even with lower STS scores 3, 4
Do not forget that TAVR carries higher rates of permanent pacemaker implantation, paravalvular leak, and valve reintervention—these complications are particularly concerning in younger patients with longer life expectancy 5
Mandatory Multidisciplinary Evaluation
All decisions must involve a Heart Valve Team including interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, heart failure specialists, and geriatric assessment when appropriate 3, 4, 6
The team evaluates surgical risk, frailty, anatomic suitability, patient preferences, and the critical balance between expected longevity versus valve durability 3, 4