What is the recommended treatment for an elderly man with severe calcific aortic stenosis and an orifice area of 0.6 cm^2?

Recommended Treatment for Severe Calcific Aortic Stenosis

This elderly man with severe calcific aortic stenosis (valve area 0.6 cm²) requires aortic valve replacement (AVR), with the specific approach—transcatheter aortic valve implantation (TAVI) versus surgical AVR (SAVR)—determined primarily by his age and whether he is symptomatic. 1

Severity Confirmation and Urgency Assessment

This patient has severe aortic stenosis by all criteria, as the valve area of 0.6 cm² is well below the 1.0 cm² threshold for severe disease 1, 2. The critical next step is determining symptom status:

• If symptomatic (heart failure, angina, syncope, exertional dyspnea, or exercise intolerance), immediate AVR is mandatory, as 1-year mortality approaches 50% and 2-year mortality reaches 75% without intervention 1, 2
• If truly asymptomatic, AVR is still indicated if left ventricular ejection fraction (LVEF) is below 50%, exercise testing reveals symptoms, or he requires other cardiac surgery 1

A common pitfall is accepting a patient's self-reported "asymptomatic" status when they have actually limited their activities to avoid symptoms—supervised exercise testing under physician observation can unmask occult symptoms 1.

Age-Based Treatment Algorithm

The choice between TAVI and SAVR follows a clear age-stratified approach 2:

• Age ≤65 years: SAVR is recommended
• Age 66-79 years: Either SAVR or TAVI is appropriate
• Age ≥80 years or estimated surgical mortality ≥8%: TAVI is recommended

For elderly patients specifically, TAVI offers decreased hospitalization length, more rapid return to normal activities, and less pain compared with SAVR, while achieving equivalent 10-year mortality (62.7% vs 64.0% for SAVR in patients over 70 with low surgical risk) 2.

Pre-Intervention Evaluation Requirements

Before proceeding with any valve replacement, the following assessments are essential 1:

• Coronary angiography to identify concomitant coronary artery disease requiring revascularization in elderly patients
• Hemodynamic assessment to exclude low-flow states, which can underestimate stenosis severity
• Multidisciplinary Heart Team evaluation involving cardiac surgery, interventional cardiology, cardiac imaging, anesthesiology, and geriatrics

Special Consideration for Low-Flow States

If this patient has reduced LVEF (<50%) with low gradients despite the small valve area, perform low-dose dobutamine stress echocardiography to distinguish true severe AS from pseudo-severe AS 1:

• True severe AS: Valve area remains ≤1.0 cm² with dobutamine, and velocity rises to ≥4 m/s or mean gradient >30-40 mmHg
• Absence of contractile reserve predicts higher surgical mortality but does not contraindicate AVR, as valve replacement may still improve LV function and outcomes 1

Critical Pitfalls to Avoid

• Never delay intervention once symptoms develop, as mortality escalates rapidly 1
• Do not rely solely on gradients in low-flow states—valve area and dobutamine stress testing are essential 1
• Ensure adequate preload during catheterization, as these patients are preload-dependent and cannot compensate for volume depletion 1
• Do not underestimate stenosis severity by accepting angle-related velocity underestimation—interrogate multiple echocardiographic windows 3