What are the guidelines for Transcatheter Aortic Valve Replacement (TAVR) in an older adult patient with severe aortic stenosis, hypertension, diabetes, and impaired renal function who is at high risk for surgical aortic valve replacement?

TAVR Guidelines for High-Risk Patients with Severe Aortic Stenosis

Primary Recommendation

TAVR is recommended for your patient with severe symptomatic aortic stenosis who is at high surgical risk, provided they have suitable aortic and vascular anatomy, predicted survival >12 months, and an estimated ≥50% risk of mortality or irreversible morbidity at 30 days from surgical aortic valve replacement. 1

Risk Stratification and Decision Framework

High-Risk Patient Criteria

Your patient qualifies as high-risk based on:

• STS score ≥8% makes TAVR a reasonable alternative to surgical AVR 1
• Comorbidities that elevate risk: diabetes, hypertension, and impaired renal function all contribute to surgical risk 1
• Additional high-risk features to assess: frailty status, prior radiation therapy, porcelain aorta, severe hepatic or pulmonary disease 1

Mandatory Heart Valve Team Evaluation

All TAVR decisions require multidisciplinary Heart Valve Team assessment including interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, and heart failure specialists 1

The team must evaluate:

• Surgical risk using validated scores (STS-PROM, EuroSCORE II) 1
• Frailty assessment (degree of disability, functional status) 1
• Cognitive function 2
• Quality of life expectations versus mortality risk 2
• Anatomic suitability for TAVR 1

Pre-Procedure Anatomic Requirements

Essential Imaging Evaluation

CT angiography of chest, abdomen, and pelvis with ECG-gated thoracic acquisition is required 1

Key anatomic assessments:

• Iliofemoral vessel diameter with minimal calcification for transfemoral access 1
• Aortic annulus sizing (end-systolic measurements between 30-40% of R-R interval) 1
• Coronary ostia height to assess risk of coronary obstruction 1
• Aortic root calcification distribution 1

Echocardiographic Requirements

Transthoracic echocardiography must confirm 1:

• Maximum aortic velocity
• Mean aortic valve gradient
• Aortic valve area
• Left ventricular ejection fraction
• Pulmonary artery pressure estimate
• Mitral valve assessment (regurgitation, stenosis, annular calcification)

Special Considerations for Your Patient

Renal Function Impact

Impaired renal function requires specific modifications 1:

• If GFR is severely reduced or patient has ESRD, minimize contrast exposure during CT angiography 1
• Consider alternative imaging with cardiac MRI if contrast is contraindicated 1
• Assess risk of acute kidney injury post-procedure (11% risk with surgical AVR, variable with TAVR) 1

Concomitant Coronary Disease

If significant coronary disease exists requiring revascularization 3:

• Coronary disease amenable to PCI should be treated with PCI before TAVR 3
• If surgical revascularization (CABG) is required, SAVR + CABG is preferred over TAVR 3

Expected Outcomes and Complications

TAVR-Specific Risks

Your patient faces these TAVR-related complications 1:

• Mortality: 3-5% at 30 days
• Stroke: 6-7%
• Vascular access complications: 17%
• Permanent pacemaker requirement: 2-43% depending on valve type (Sapien 2-9%, CoreValve 19-43%)
• Paravalvular aortic regurgitation: common complication requiring assessment
• Acute kidney injury: particularly relevant given existing renal impairment

Comparative Surgical AVR Risks

For context, surgical AVR carries 1:

• Mortality: 3%
• Stroke: 2%
• Prolonged ventilation: 11%
• Higher complications when combined with CABG

Futility Assessment

TAVR should not be performed if expected benefit is less than expected risk 1, 2

Futility indicators include 2:

• Multiple organ system failure (≥2 major organs severely compromised)
• Severe frailty with complete functional dependence
• Advanced cognitive impairment
• Life expectancy <12 months from non-cardiac causes 1
• Patient goals incompatible with realistic procedural outcomes

If TAVR is deemed futile, medical management with afterload reduction or palliative care is appropriate 2

Post-Procedure Follow-Up

Immediate Post-TAVR Monitoring

Transthoracic echocardiography is required to assess 1:

• Maximum aortic velocity and mean gradient
• Aortic valve area
• Paravalvular and valvular regurgitation severity
• Left ventricular function and geometry
• Pulmonary pressure

Long-Term Surveillance

Serial echocardiography at specified intervals to monitor valve function, paravalvular regurgitation progression, and ventricular remodeling 1

Critical Exclusions

TAVR is categorically contraindicated for severe aortic regurgitation regardless of surgical risk, as devices were designed exclusively for calcified stenotic valves 4, 5