A 75-year-old man has severe aortic stenosis (aortic valve area 0.72 cm², mean gradient 52 mmHg) with an LVEF of 62% and is symptomatic with exertional dyspnoea. He has multiple comorbidities including COPD and prior CABG. His STS surgical mortality risk is 9%. Which treatment is recommended by current guidelines?

• A Transcatheter aortic valve implantation (TAVI) ✓
• B Surgical aortic valve replacement (SAVR)
• C Medical management with diuretics and serial echocardiography
• D Balloon aortic valvuloplasty as bridge to SAVR

Explanation

ACC/AHA 2021 Valvular Heart Disease guidelines recommend TAVI as the preferred strategy for patients with symptomatic severe AS who are at high surgical risk (STS score ≥ 8%) or intermediate risk (STS score 4–8%). This patient has an STS score of 9% (high risk) and prior CABG making redo sternotomy particularly hazardous. The PARTNER and CoreValve high-risk trials established TAVI equivalence or superiority to SAVR in high-risk patients. Medical management is inappropriate for symptomatic severe AS. Balloon valvuloplasty has high re-stenosis rates and is a palliative bridge only.

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

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Written and medically reviewed by the StethoPrep medical team.