What treatment options are available for an older adult patient with severe aortic stenosis, significant comorbidities such as coronary artery disease (CAD), chronic kidney disease (CKD), and chronic obstructive pulmonary disease (COPD), who is considered high risk for surgical aortic valve replacement and may be a candidate for Transcatheter Aortic Valve Implantation (TAVI)?

TAVI for High-Risk Severe Aortic Stenosis

Primary Recommendation

TAVI is the recommended treatment for this older adult patient with severe symptomatic aortic stenosis and multiple high-risk comorbidities (CAD, CKD, COPD), as these conditions place the patient at prohibitive or high surgical risk for conventional aortic valve replacement. 1, 2

Risk Stratification Framework

Your patient meets criteria for TAVI through multiple pathways:

• Calculate the STS score first: If ≥8%, TAVI is a reasonable alternative to surgical AVR 3, 1, 2
• Prohibitive risk criteria (≥50% estimated 30-day mortality or irreversible morbidity): The combination of CAD, CKD, and severe COPD likely meets this threshold 3, 1
• Specific high-risk features present: Severe pulmonary disease (COPD) is explicitly listed as a prohibitive risk factor 3, 1

The presence of CKD and CAD further elevates surgical risk beyond the STS score alone. 1

Mandatory Pre-Procedure Requirements

Heart Team Evaluation

A multidisciplinary Heart Team assessment is required before proceeding, including interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, and heart failure specialists. 3, 1, 2

Anatomic Assessment

CT angiography of chest, abdomen, and pelvis with ECG-gated thoracic acquisition is mandatory to evaluate: 1, 2

• Iliofemoral vessel diameter (minimum 6 mm required for transfemoral access) 4
• Aortic annulus sizing for device selection 3, 1
• Coronary ostia height 1, 2
• Aortic root calcification distribution 1, 2

For your patient with CKD: Minimize contrast exposure during CT; consider cardiac MRI if contrast is contraindicated. 1, 2

Echocardiographic Confirmation

Transthoracic echocardiography must confirm severe AS with at least one of: 3, 1, 2

• Maximum aortic velocity ≥4.0 m/s
• Mean gradient ≥40 mmHg
• Aortic valve area ≤1.0 cm²

Additional assessment includes LV ejection fraction, pulmonary artery pressure, and mitral valve function. 1

Survival Requirement

Predicted survival must exceed 12 months from non-cardiac causes. 3, 1, 2 This is critical—if life expectancy is <12 months due to comorbidities, TAVI should not be performed. 1, 2

Management of Concomitant CAD

For significant left main or proximal CAD: Perform PCI before TAVI. 2

For complex multivessel CAD with SYNTAX score >33: Surgical AVR with CABG is preferred over TAVI with PCI, but this may not be feasible given your patient's high surgical risk. 2

Expected Outcomes and Complications

Be transparent with the patient about TAVI-specific risks: 3, 1, 2

• 30-day mortality: 3-5%
• Stroke: 6-7% (higher than surgical AVR's 2%)
• Vascular access complications: 17%
• Permanent pacemaker requirement: 2-9% (Sapien valve) or 19-43% (CoreValve)
• Acute kidney injury: Elevated risk given pre-existing CKD 1, 2
• Paravalvular aortic regurgitation: Common complication 3, 5

Compare this to surgical AVR risks (mortality 3%, stroke 2%, prolonged ventilation 11%), though these rates would be substantially higher in your high-risk patient. 3, 1

Futility Assessment

Do not proceed with TAVI if any of the following apply: 1, 2

• Multiple organ system failure
• Severe frailty with inability to recover functional capacity
• Advanced cognitive impairment
• Life expectancy <12 months from non-cardiac causes
• Patient goals incompatible with realistic procedural outcomes

Frailty assessment is particularly important, as it independently predicts poor outcomes. 4, 6

Alternative Treatment Options

Balloon Aortic Valvuloplasty

Consider only as a bridge to TAVR or for palliation, not as definitive therapy, given its limited long-term efficacy. 3, 7

Medical Management

If TAVI is not feasible: Use cautious diuretics for symptom relief, but avoid excessive diuresis, vasodilators, and positive inotropes as they risk hemodynamic destabilization. 3, 7 Medical therapy does not improve survival in symptomatic severe AS. 3

Conservative Management

Approximately 37% of high-risk patients referred for TAVI are ultimately treated conservatively, with 30-day mortality of 32% in this group. 6

Post-Procedure Surveillance

Immediate post-TAVI echocardiography is required to assess valve function, paravalvular regurgitation, LV function, and pulmonary pressures. 1, 2

Serial echocardiography at specified intervals monitors for valve dysfunction, paravalvular regurgitation progression, and ventricular remodeling. 1, 2

Critical Pitfalls to Avoid

• Do not rely solely on STS score: Frailty, COPD severity, and other factors not captured by risk calculators must be considered. 4, 6
• Do not proceed without adequate vascular access: Transfemoral approach requires minimum 6 mm vessel diameter; alternative access routes (subclavian, axillary, apical) may be needed. 3, 4
• Do not underestimate stroke risk: At 6-7%, this is triple the surgical AVR rate and warrants careful patient counseling. 3, 1, 2
• Do not ignore the CKD: Acute kidney injury post-TAVR is a significant risk in patients with pre-existing renal impairment. 1, 2