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Ramesh Patel, AHMAD MORSHED Commented on a Post
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TAVR Suitability in the Low-Risk Patient

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?

  • August 24, 2022
    A cardiology clinician would have heart catheterization with coronaries. Then have a discussion with the patient and family. Answer all questions and if agreed upon, refer for TAVR that would be performed while the clinician still in charge for post-procedure care.
  • August 14, 2022
    Need coronary angiogram first. If complex cad or left main or severe Ted then cabg and savr but if no cad or cad with discrete lesion then TAVR
  • July 17, 2022
    refer to tavr team for evaluations and consider tavr
  • July 15, 2022
    Patient needs to have PCI to see if patient has a coronavirus disease or not before to do any intervention
  • July 03, 2022
    How have your TAVR patients fared vs. your SAVR patients?
  • July 03, 2022
    Considering benefits/drawbacks of TAVR and SAVR in this patient and woud vote for TAVR
  • June 22, 2022
    Thanks, All, for your wonderful contributions! What are some trends you have noticed with regard to TAVR vs. SAVR? Are these trends supported by strong evidence? Please explain?
  • June 21, 2022
    @Keith Attasi I have no real qualms about putting people with AS on a treadmill if I've spoken to them personally first and am convinced that they are "asymptomatic" (or mildly symptomatic) but without knowing this patient's coronary anatomy, what am I to make of an abnormal result? Probably a little bit more risky unless she is known to not have CAD. If she is free of CAD and truly, TRULY asymptomatic with a good functional capacity I'm not averse to having them wait, but at age 70+, what exactly are we waiting for? The best patient to do a procedure on is one who is not on any downslope.
  • June 21, 2022
    Needs a coronary angiogram obviously. If severe/LM/3 vessel CAD is present I think the consensus would still be SAVR + CAB. In my practice this has happened about twice within the past year and almost all AS is being done via TAVR if mild/single-vessel or no CAD is present.

    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.
  • June 07, 2022
    Thanks, All, for your wonderful input! What role would consultation with a heart-valve team play in the care of this patient? What would happen if the heart-valve team made a recommendation that was different from your initial recommendation? How often does your assessment differ from that of a multidisciplinary team? Also, what role does CAD play in the treatment of this patient?
  • June 07, 2022
    Another option is to do an MRI to look for myocardial fibrosis which can inform the urgency of pursuing an aggressive approach. The aforementioned comments are the usual suspects.
  • May 31, 2022
    will anybody consider doing a stress test on her ,to evaluate her functional capacity, hemodynamic response, ect ,then decide if she really needs intervention now ,or may be defer for a while !! she is totally asymptomatic & very functional for her age
    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!!"

  • May 27, 2022
    Most likely would recommend TAVR, unless she is found to have multivessel or Left main CAD. The benefit of avoiding a pump run is meaningful, and even if she has some CAD that could be addressed with medical therapy or low risk PCI, I think TAVR would be favored.
  • May 26, 2022
    Patient will be referred to our heart team
  • May 25, 2022
    Need more data. Cath will be the first step. If severe, complex CAD that warrants CABG, then best served with CABG and bio SAVR. If no CAD or discrete CAD amenable to PCI, then TAVR +/- PCI is reasonable. Multidisciplinary Heart Team evaluation is invaluable to guide the patient, once all data available.
  • May 24, 2022
    Most previous clinicians agree that this patient needs LHC/cor. angio before proceeding. In this age I would discuss results and options carefully with patient after angio, then refer her case to Heart Team, to obtain the best combination opinion from surgical, interventional, and other perspectives. If no significant CAD, I would probably lean (with her expressed preference) to TAVR.
  • May 24, 2022
    Would definitely arrange for LHC/angiogram first; if sig CAD would consider CABG+SAVR, but otherwise could consider TAVR but she is lower risk and relatively young. Ultimately a heart team visit would need to weigh pros and cons with the patient but TAVR is now so much easier and faster recovery.
  • May 24, 2022
    Would obtain cath to check for CAD first, then possible CABG/AVR vs consider low risk TAVR if no sig CAD OR if PCI candidate.
  • May 24, 2022
    She is low risk so technically she is a SAVR candidate but I am sure she is aware of lower risk Partner data so would prefer a TAVR. I’d put her in a low risk TAVR trial (but she could randomize to SAVR!)
  • May 24, 2022
    Recommend heart valve team consultation for shared decision making that involves results of coronary angiogram and TAVR - CTA results and if favorable anatomy and coronary arteries, then TAVR would be treatment of choice.
  • May 24, 2022
    First needs a heart cath to see if concomitant CAD.
    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.
  • May 24, 2022
    if patient needs CABG based on CATH then SAVR otherwise, TAVR
  • May 24, 2022
  • May 24, 2022
    depends on cath-- if cath show cad requiring cabg then would do SAVR-- otherwise would do TAVR
  • May 16, 2022
    does she have critical CAD. if so combined surgical valve replacement with coronary revascularization .
  • May 16, 2022
    TAVR as first choice.
  • May 09, 2022
    What are the benefits/drawbacks of TAVR and SAVR in this patient and more generally?
  • May 09, 2022