A 70-year-old man with severe aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg, LVEF 55%) is evaluated for intervention. He has moderate COPD, previous CABG 7 years ago, and STS operative mortality risk score of 6.2%. Which intervention is preferred per ACC/AHA 2021 guidelines?

• A Balloon aortic valvuloplasty as definitive therapy
• B TAVR (transcatheter aortic valve replacement) is preferred given intermediate surgical risk ✓
• C SAVR (surgical aortic valve replacement) given preserved EF
• D Medical therapy and watchful waiting until EF drops

Explanation

For severe symptomatic AS, TAVR is now recommended as an equivalent or preferred alternative to SAVR in patients at intermediate (STS 4–8%), high (STS >8%), or prohibitive surgical risk. The PARTNER 2 and SURTAVI trials demonstrated non-inferiority of TAVR to SAVR at intermediate risk. Per 2021 AHA/ACC Valvular Heart Disease guidelines, TAVR is preferred (Class I) in patients ≥65 years with anatomy suitable for TAVR who are at high or prohibitive surgical risk, and is reasonable (Class IIa) for intermediate risk. Balloon valvuloplasty is only a bridge to definitive therapy.

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

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Written and medically reviewed by the StethoPrep medical team.