What is the best treatment option for an older adult 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 is being considered for Transcatheter Aortic Valve Implantation (TAVI)?

TAVI for High-Risk Severe Aortic Stenosis with Multiple Comorbidities

TAVI is the recommended treatment for this patient with severe symptomatic aortic stenosis and high surgical risk from multiple comorbidities (CAD, CKD, COPD), provided the patient has suitable transfemoral anatomy, predicted survival exceeds 12 months, and meets prohibitive or high-risk criteria. 1, 2

Risk Stratification Confirms TAVI Indication

Your patient clearly meets high-risk criteria through multiple pathways:

• COPD qualifies as oxygen-dependent lung disease, which the American College of Cardiology explicitly identifies as a prohibitive risk factor favoring TAVI over surgical AVR 3
• CKD requiring dialysis is specifically listed as a Class A indication for TAVI 3
• STS-PROM score ≥8% makes TAVI a reasonable alternative to surgical AVR, while ≥50% estimated 30-day mortality or irreversible morbidity risk establishes prohibitive surgical risk 3, 1, 2
• Additional high-risk features include frailty status and the presence of multiple organ system compromise 3, 2

Mandatory Pre-Procedure Requirements

Before proceeding with TAVI, you must complete:

• Multidisciplinary Heart Team evaluation including interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, and heart failure specialists 1, 2
• CT angiography of chest, abdomen, and pelvis with ECG-gated thoracic acquisition to assess iliofemoral vessel diameter, aortic annulus sizing, coronary ostia height, and aortic root calcification distribution 1, 2
• For this patient with CKD, minimize contrast exposure during CT angiography and consider cardiac MRI as alternative imaging if contrast is contraindicated 1, 2
• Transthoracic echocardiography confirming maximum aortic velocity ≥4 m/s, mean gradient ≥40 mmHg, or aortic valve area ≤1.0 cm² 1

Managing Concomitant CAD

The presence of CAD requires specific decision-making:

• If significant left main or proximal CAD exists, perform PCI before TAVR 1
• However, if complex bifurcation left main and/or multivessel CAD with SYNTAX score >33 is present, surgical AVR with CABG is preferred over TAVR with PCI 1
• This represents the one scenario where surgical AVR might still be considered despite high risk, though the patient's COPD and CKD likely make this prohibitive 3

Predicted Survival Assessment

Confirm predicted survival exceeds 12 months from non-cardiac causes 1, 2. Futility criteria that would contraindicate TAVI include:

• Life expectancy <12 months from non-cardiac causes 3, 1, 2
• Multiple organ system failure 2
• Severe frailty with inability to recover functional capacity 3, 2
• Advanced cognitive impairment or patient goals incompatible with realistic procedural outcomes 2

Expected Outcomes and Complications

Counsel the patient on TAVI-specific risks:

• 30-day mortality: 3-5% 3, 1, 2
• Stroke: 6-7% 3, 1, 2
• Vascular access complications: 17% 3, 1, 2
• Permanent pacemaker requirement: 2-9% (Sapien valve) or 19-43% (CoreValve) 3, 1
• Acute kidney injury risk is elevated given pre-existing CKD 1, 2
• Paravalvular aortic regurgitation occurs but is usually trivial or mild 4

These TAVI risks compare favorably to surgical AVR risks in high-risk patients (surgical mortality 3%, stroke 2%, prolonged ventilation 11%), but the patient's comorbidities substantially increase surgical risk beyond these baseline figures 3, 2

Post-Procedure Surveillance

Immediately post-TAVR, obtain transthoracic echocardiography to assess maximum aortic velocity, mean gradient, aortic valve area, paravalvular and valvular regurgitation severity, left ventricular function, and pulmonary pressure 1, 2

Serial echocardiography at specified intervals is required for long-term surveillance to monitor valve function, paravalvular regurgitation progression, and ventricular remodeling 1, 2

Critical Caveat: Bicuspid Valve Exclusion

If imaging reveals bicuspid aortic valve anatomy, TAVI is explicitly not recommended regardless of surgical risk because insufficient data exist on the risk/benefit ratio 5. This would require surgical AVR or conservative management 5.