What is the best treatment option for a patient with severe calcific aortic stenosis, symptoms such as chest pain, shortness of breath, or fainting, and comorbidities like coronary artery disease, chronic kidney disease, or chronic obstructive pulmonary disease, who is at high risk for surgical aortic valve replacement?

TAVR for Severe Calcific Aortic Stenosis in High-Risk Patients

TAVR is the recommended treatment for patients with severe symptomatic calcific aortic stenosis who are at high or prohibitive surgical risk, provided they have suitable anatomy, predicted survival >12 months, and meet specific risk thresholds. 1

Risk Stratification Determines Treatment Choice

Prohibitive Surgical Risk (TAVR Strongly Recommended)

• TAVR is indicated when estimated surgical mortality is ≥50% at 30 days or when irreversible morbidity risk is ≥50%. 2, 1
• Additional prohibitive risk factors include frailty, prior chest radiation, porcelain aorta, severe hepatic disease, or severe pulmonary disease. 2, 1
• These patients should proceed directly to TAVR without consideration of surgical AVR. 2

High Surgical Risk (TAVR is Reasonable Alternative)

• TAVR is a reasonable alternative to surgical AVR when STS-PROM score is ≥8%. 2, 1, 3
• The original PARTNER trial used STS ≥10%, but this was revised to ≥8% during enrollment. 2
• Comorbidities contributing to high risk include diabetes, hypertension, impaired renal function, coronary artery disease, chronic kidney disease, and COPD. 1

Age-Based Recommendations

• For patients ≥80 years old with suitable anatomy, TAVR is preferred over surgical AVR. 2
• For ages 65-79 years, either TAVR or surgical AVR is reasonable based on individual factors. 2, 4
• For patients <65 years, surgical AVR is preferred due to limited long-term TAVR durability data beyond 5 years. 2, 4

Mandatory Pre-Procedure Requirements

Heart Team Evaluation

• A multidisciplinary Heart Team assessment is required for all TAVR decisions, including interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, and heart failure specialists. 1, 3
• This team-based approach is foundational given the complexity of the procedure and high-risk patient profile. 2

Anatomic Assessment

• CT angiography of chest, abdomen, and pelvis with ECG-gated thoracic acquisition is required for anatomic evaluation. 1
• Critical measurements include iliofemoral vessel diameter (must accommodate 22-24F sheath for transfemoral approach), aortic annulus sizing, coronary ostia height, and aortic root calcification distribution. 2, 1
• Transthoracic echocardiography must confirm severe AS with maximum aortic velocity ≥4 m/s, mean gradient ≥40 mmHg, or aortic valve area ≤1.0 cm². 1, 3, 4

Predicted Survival Requirement

• Predicted survival must exceed 12 months from non-cardiac causes. 2, 1
• This requirement ensures patients can experience meaningful benefit from the intervention. 1

Management of Concomitant Coronary Artery Disease

For patients with significant left main or proximal CAD, revascularization by PCI before TAVR is reasonable. 2

• Retrospective data suggest procedural risk does not increase with conservative medical management of CAD during TAVR. 2
• However, some studies show higher 1-year mortality in CAD patients after TAVR. 2
• For complex bifurcation left main and/or multivessel CAD with SYNTAX score >33, surgical AVR with CABG is preferred over TAVR with PCI. 2
• PCI can be performed safely in severe AS patients, but those with LVEF depression or STS-PROM >10% have 30-day mortality >10% after PCI. 2

Expected Outcomes and Complications

TAVR-Specific Risks

• 30-day mortality: 3-5% 2, 1
• Stroke: 6-7% 2, 1
• Vascular access complications: 17% 2, 1
• Permanent pacemaker requirement: 2-9% (Sapien valve) or 19-43% (CoreValve) 2, 1
• Paravalvular aortic regurgitation (variable severity) 2, 1
• Acute kidney injury (particularly relevant for patients with pre-existing renal impairment) 2, 1

Comparative Surgical AVR Risks

• 30-day mortality: 3% 2, 1
• Stroke: 2% 2, 1
• Prolonged ventilation: 11% 2, 1

TAVR offers decreased hospitalization length, more rapid return to activities, and less pain compared to surgical AVR, which is particularly advantageous in high-risk elderly patients. 4

Contraindications and Futility Criteria

Absolute Contraindications

• TAVR should not be performed when expected survival is <12 months from non-cardiac causes. 2, 1
• Multiple organ system failure 1
• Severe frailty with inability to recover functional capacity 2, 1
• Advanced cognitive impairment (moderate to severe dementia) 2
• Patient goals incompatible with realistic procedural outcomes 1

Additional Futility Indicators

• Bedbound or non-mobile status 2
• Cachexia or severe sarcopenia 2
• Disability requiring assistance for most activities of daily living 2
• End-stage renal, liver, lung disease, or malignancy 2

Special Populations

Patients with Chronic Kidney Disease

• Minimize contrast exposure during CT angiography. 1
• Consider cardiac MRI as alternative imaging if contrast is contraindicated. 1
• Acute kidney injury risk post-TAVR is elevated in patients with pre-existing renal impairment. 2, 1

Urgent TAVR for Acute Decompensated Heart Failure

• For patients with severe AS presenting with acute refractory heart failure despite medical therapy, urgent TAVR during the same hospitalization is a viable strategy. 5
• Short-term outcomes after urgent TAVR appear reasonable with similar 30-day mortality compared to elective TAVR. 5
• Pulmonary edema is the most common presentation requiring urgent intervention. 5

Post-Procedure Surveillance

Transthoracic echocardiography is required immediately post-TAVR to assess maximum aortic velocity, mean gradient, aortic valve area, paravalvular and valvular regurgitation severity, left ventricular function, and pulmonary pressure. 1

• Serial echocardiography at specified intervals is required for long-term surveillance to monitor valve function, paravalvular regurgitation progression, and ventricular remodeling. 1

Critical Pitfalls to Avoid

• Do not perform TAVR for severe aortic regurgitation—it is explicitly excluded from current indications regardless of surgical risk. 6
• Do not proceed with TAVR without formal Heart Team evaluation. 2, 1
• Do not perform TAVR when anatomic assessment shows unsuitable iliofemoral access without considering alternative access routes (transapical, transaortic). 2
• Do not overlook frailty assessment—frailty may predict poor functional recovery despite technically successful TAVR. 2, 1