A 65-year-old man has severe aortic stenosis (valve area 0.7 cm², mean gradient 52 mmHg) and is symptomatic with dyspnea on exertion and syncope. He has previous CABG with a patent LIMA-LAD graft. STS score is 5.2%. According to AHA/ACC 2021 VHD guidelines, what is the preferred intervention?
- A Transcatheter aortic valve implantation (TAVI/TAVR) ✓
- B Surgical aortic valve replacement (SAVR)
- C Balloon aortic valvuloplasty as a bridge
- D Medical management with diuretics
Correct answer: A. Transcatheter aortic valve implantation (TAVI/TAVR)
Explanation
AHA/ACC 2021 guidelines recommend TAVR (TAVI) for symptomatic severe AS in intermediate-risk patients (STS PROM 4–8%) and in high-risk/prohibitive-risk patients. In this patient with STS score of 5.2% (intermediate risk), multiple RCTs (PARTNER 2, SURTAVI, NOTION) demonstrated TAVR is non-inferior to SAVR; prior CABG with patent LIMA-LAD graft increases the risk of repeat sternotomy and operative mortality, further favouring TAVR. SAVR remains preferred in low-risk patients (<4% STS PROM) with suitable anatomy.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.