72-year-old hypertensive woman with a family history of coronary artery disease presents with a 3-month history of functional class II dyspnea on exertion (New York Heart Association). The patient has an active lifestyle and plays pickleball 4 x/week with friends. She is currently taking lisinopril 5 mg every day. She complains of neither chest pain nor palpitations.
Physical exam findings
- Pulse: 88 bpm
- Respiration rate: 19/min
- Blood pressure: 110/80 mmHg without orthostatic changes
- Heart sounds: midsystolic ejection murmur heard best at the right upper sternal border
Results from her CBC and CMP were within normal limits.
On echo, there is a mean gradient 42 mmHg, peak aortic velocity of 4.1 m/s, and aortic valve area of 0.9 cm2. Results from the CCT confirmed severe aortic stenosis.
Her Society of Thoracic Surgeons risk is 1.8%. Her projected life expectancy is about 15 years. During patient visit, she expressed a preference for TAVR vs SAVR.
Based on this information, what interventions do you anticipate could be recommended for this patient? What information would you need to decide on TAVR or SAVR for this patient? Would you rather defer this patient to a heart-team to make the treatment decision?
I don't personally think this needs heart team discussion--at my institution heart team is for very complex patients with very difficult decisions to make. However, virtually all patients with aortic stenosis go through the Structural Heart service, which is a different entity.
risk of sudden death also is low .
what is her calcium score" aortic valve calcium score "
in my area ,valve team leans "most of time" toward TAVR!! ,
if decide on intervention ,& based on her anatomy ,I will probably recommend SAVR+ CABG , as 1st option
TAVR, +/_ Ptca as second option
obviously the patient will have a lot to say ,when she hears these options 'Based on how options are presented to her!!"
If relatively straightforward stent case, would do prior.
If severe CAD, will need SAVR with tissue valve and bypass.
If no CAD, TAVR
Huge benefit to avoid surgery, pump, etc.