Your 66-year-old patient with symptomatic aortic stenosis and advanced calcification of the valve is otherwise healthy, without severe comorbidities, and of normal weight. However, in case in the future, the patient needs a PCI (percutaneous coronary intervention), you would like to retain coronary access (for example, if they have dyslipidemia which is well controlled and currently without known atherosclerotic cardiovascular disease). In addition, given the relatively young age yet good health, the patient likely will need 2-3 aortic valve replacements during their lifetime.

Assuming the patient meets criteria for needing aortic valve replacement (AVR), would you recommend TAVR (transcatheter aortic valve replacement, also known as TAVI) or SAVR (surgical aortic valve replacement) as the first-line treatment?

What factors affect that recommendation? What considerations go into that decision?

If you are referring to a Heart Team, who do you refer to and what does that communication pathway look like?

Aortic stenosis (AS) is the most common heart valve disease, characterized by the narrowing of the aortic valve due to progressive calcification. Treatment paradigms have shifted to expand the use of less-invasive transcatheter aortic valve replacement (TAVR) vs surgical aortic valve replacement (SAVR). Since TAVR approval in 2013, the FDA has granted multiple label expansions to include a “valve-in-valve” procedure for failed surgical bioprosthetic valves (2015), use in patients with severe AS at intermediate risk (2016), and use in severe AS patients with low surgical risk (2019). This represents a significant advancement as 75% of severe AS patients are categorized as low-to-intermediate surgical risk.

In the PARTNER 3 study, which compared TAVR to SAVR in low-risk patients, the findings showed:
the primary composite endpoint of death, stroke, or rehospitalization was significantly lower in the TAVR group (8.5% vs. 15.1%; p<0.001)
TAVR had a shorter index hospitalization (p<0.001)
at 30 days there was a lower stroke risk and lower incidence of new atrial fibrillation in the TAVR group
Though there was a higher incidence of new Left Bundle Branch Block in the TAVR group, there was not a significant difference in the need for a permanent pacemaker in the two groups.

1. What are the clinical triggers that would prompt you to consider TAVR intervention in severe AS patients with low-to-intermediate surgical risk?
2. In which types of patients do you believe TAVR is preferable to SAVR?
3. What are the potential advantages and disadvantages of conducting TAVR versus SAVR in patients with severe aortic stenosis?