A 68-year-old woman with severe aortic stenosis (mean gradient 58 mmHg, AVA 0.7 cm², LVEF 55%) is referred for definitive therapy. She has COPD GOLD Grade 3, prior stroke with mild residual deficit, and porcelain aorta on CT. STS predicted risk of mortality for SAVR is 9.2%. What is the preferred valve replacement strategy per current ACC/AHA 2021 guidelines?

• A Surgical aortic valve replacement (SAVR) with concomitant coronary bypass if needed
• B Balloon aortic valvuloplasty as a bridge to decision
• C Transcatheter aortic valve replacement (TAVR) is the preferred approach ✓
• D Medical management with optimised diuretics and ACE inhibitors

Explanation

Per the 2021 ACC/AHA valvular heart disease guidelines, TAVR is the preferred strategy for severe symptomatic AS in patients with high surgical risk (STS score ≥ 8% or presence of major surgical risk factors). This patient has an STS score of 9.2%, porcelain aorta (a major contraindication to conventional SAVR due to inability to cannulate/clamp the aorta), prior stroke, and severe COPD — all high-risk features. PARTNER 1 and PARTNER 2 trials demonstrated non-inferiority of TAVR vs SAVR in high- and intermediate-risk patients. TAVR has expanded to low-risk patients (PARTNER 3, EVOLUT LOW RISK). Balloon valvuloplasty provides only temporary benefit with high restenosis rate. Medical therapy does not alter the natural history of severe AS.

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

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Written and medically reviewed by the StethoPrep medical team.