In a patient over 70 years old with severe aortic stenosis who is high‑risk or inoperable for surgery, are a left ventricular ejection fraction less than 35% and severe pulmonary hypertension contraindications to transcatheter aortic valve implantation (TAVI)?

TAVI in Severe Reduced LVEF and Severe Pulmonary Hypertension

Neither severely reduced LVEF below 35% nor severe pulmonary hypertension are absolute contraindications to TAVI, though they significantly increase procedural risk and require careful Heart Team evaluation.

LVEF Below 35%: A Relative, Not Absolute Contraindication

LVEF <20% is listed as a relative contraindication, but LVEF 20-35% is not contraindicated for TAVI. 1

• The 2012 European Society of Cardiology guidelines specifically list "LVEF <20%" as a relative contraindication, not an absolute one 1
• Importantly, LVEF between 20-35% does not appear in contraindication lists, making it acceptable for TAVI consideration 1
• Patients with severely reduced LVEF actually demonstrate superior LVEF recovery after TAVI compared to surgical AVR, with 58% achieving normalization (>50%) at 1 year versus only 20% with surgery 2
• Lower baseline LVEF independently predicts better LVEF recovery after TAVI 2
• Patients with baseline LVEF <40% show the greatest absolute improvement in LVEF post-TAVI (from 33% to 43% at 12 months) 3

Clinical Implications for Reduced LVEF

• The presence of reduced LVEF increases mortality risk but does not preclude TAVI 4
• LVEF is incorporated into risk prediction models as a continuous variable affecting outcomes, not as a binary exclusion criterion 4
• The key question is whether the reduced LVEF represents afterload mismatch (reversible) versus primary myocardial disease (less reversible) 2
• Dobutamine stress echocardiography can help differentiate true severe stenosis with contractile reserve from pseudosevere stenosis 5, 6

Severe Pulmonary Hypertension: Approach-Specific Relative Contraindication

Severe pulmonary hypertension is listed as a relative contraindication only for the transapical approach, not for transfemoral TAVI. 1

• The 2012 ESC guidelines specifically state "severe pulmonary disease" as a relative contraindication for the transapical approach only 1
• Transfemoral TAVI remains feasible in patients with severe pulmonary hypertension 1
• The 2008 ESC/EACTS position statement lists "severe respiratory insufficiency" as a contraindication for transapical approach but does not restrict transfemoral access 1

Understanding PH Mechanism in Aortic Stenosis

• In elderly patients with severe AS, pulmonary hypertension is predominantly due to left heart congestion (elevated pulmonary artery wedge pressure), not intrinsic pulmonary vascular disease 7
• Pulmonary vascular resistance typically remains <3 Wood units despite elevated PA pressures 7
• The transpulmonary gradient and diastolic pulmonary gradient remain in normal range in most cases 7
• PH in severe AS functions as a "heart failure equivalent" rather than primary pulmonary vascular disease 7

Risk Stratification with PH

• PH is a predictor of both 30-day and 1-year mortality after TAVI, with risk magnitude similar to major vascular complications and renal insufficiency 1
• Patients with PH are more susceptible to hemodynamic and electrical instability during the procedure 1
• Right heart failure and severe tricuspid regurgitation may complicate management 1
• Despite increased risk, PH does not constitute an absolute contraindication when proper patient selection and procedural planning occur 1

Mandatory Heart Team Evaluation

All high-risk patients, particularly those with LVEF <35% or severe PH, require multidisciplinary Heart Team assessment including interventional cardiologists, cardiac surgeons, imaging specialists, anesthesiologists, and heart failure specialists. 6, 8

Pre-Procedural Assessment Requirements

• CT angiography with ECG-gated thoracic acquisition to evaluate anatomy 6
• Comprehensive transthoracic echocardiography assessing LVEF, pulmonary artery pressures, mitral valve function, and aortic valve hemodynamics 6
• Right heart catheterization should be considered to precisely characterize PH severity and mechanism 1, 7
• Assessment of frailty, comorbidities, and predicted survival >12 months 6

Common Pitfalls to Avoid

• Do not automatically exclude patients with LVEF 20-35%—these patients may derive the greatest benefit from TAVI 2, 3
• Do not confuse transapical contraindications with transfemoral contraindications—severe PH only restricts transapical access 1
• Do not assume PH in AS represents primary pulmonary vascular disease—it is usually reversible left heart congestion 7
• Ensure adequate hemodynamic monitoring and anesthesia support for patients with PH who are at higher risk of procedural instability 1
• Consider coronary artery disease and prior MI as factors that may limit LVEF recovery, though they do not contraindicate TAVI 3

Futility Assessment

TAVI should not be performed if expected survival is <12 months from non-cardiac causes, multiple organ system failure is present, or patient goals are incompatible with realistic outcomes. 6

• The combination of LVEF <35% and severe PH increases mortality risk but does not automatically indicate futility 4
• Assess whether quality of life improvement is achievable given the patient's overall condition 1, 6