A 72-year-old man with severe aortic stenosis (AVA 0.6 cm², mean gradient 55 mmHg) and EF of 25% presents for evaluation. His STS surgical mortality risk score is 12%. He has severe COPD and peripheral vascular disease. Which intervention is most appropriate according to ACC/AHA 2021 guidelines?

• A Surgical aortic valve replacement (SAVR)
• B Transcatheter aortic valve replacement (TAVR) ✓
• C Medical management; intervention is too high risk
• D Balloon aortic valvuloplasty as bridge to definitive therapy

Explanation

TAVR is indicated for severe symptomatic aortic stenosis in patients with high surgical risk (STS score >8% or equivalent risk from PARTNER trial criteria) or when there are specific anatomic/clinical features making surgical risk prohibitive (severe COPD, prior sternotomy, PVD). The PARTNER 1 and 2 trials showed TAVR non-inferior to SAVR in high-risk patients and superior to medical therapy in inoperable patients. With EF 25% (low-flow, low-gradient AS), dobutamine stress echo or CT calcium scoring helps confirm true severe AS before TAVR. PARTNER 3 and EVOLUT trials now extend TAVR even to low-risk patients.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.