A 70-year-old man with severe aortic stenosis (AVA 0.7 cm², mean gradient 52 mmHg) has NYHA class III dyspnoea. Echocardiogram shows EF of 35% (severe LV dysfunction). Per current ACC/AHA 2021 guidelines on valvular heart disease, the surgical risk is assessed as high. Which intervention is indicated?

• A Valve replacement should be deferred until EF recovers with medical therapy
• B Medical management with sacubitril/valsartan and diuretics
• C Balloon aortic valvuloplasty as definitive treatment
• D Transcatheter aortic valve replacement (TAVR) is indicated (Class I recommendation) ✓

Explanation

Severe symptomatic AS with EF <50% and high surgical risk is a Class I indication for TAVR per ACC/AHA 2021 guidelines (and ESC 2021). TAVR has been validated across high, intermediate, and low surgical risk groups (PARTNER, CoreValve, NOTION, EVOLUT trials). Low EF in AS is not a contraindication and can improve after AVR as afterload mismatch is relieved. Surgical AVR is the alternative for low-intermediate risk patients. Balloon valvuloplasty provides only temporary benefit and is used as a bridge to AVR or in those too unwell for definitive intervention.

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

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Written and medically reviewed by the StethoPrep medical team.