Home > Focus Areas > Aortic Stenosis Connect > Post
  • Saved

made a Post

5yr

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?

  • 5yr
    Patient will need coronary angiogram before any interventions. I would send him for SAVR at the age of 66 ( with or without obstructive CAD). Patient will have an option of TAVR in future ( when he requires first replacement ). There is Heart Team at our institution, but for healthy 66 y.o. male SAVR should be first option.
  • 5yr
    At age 66, all patients would have coronary angiography prior to making a decision on valve replacement. If there is no coronary artery disease or it is amenable to PCI most patients would have TAVR. If there is aortic disease ie aneurysm then surgical option is preferable. The possibility of valve in valve decreases the risk of TAVR long term
  • 5yr
    I would still prefer TAVR. THe sapien valve has a relatively low profile but even the medtronic valve can still allow coronary artery access. For me TAVR still has many more advantages.
  • 5yr
    First, noninvasive testing, including perfusion and functional testing for significant obstructive CAD. Then coronary angiography with concomitant transvalvular and, if indicated, flow reserve measurements. With these data in hand, and after thorough discussion of options with patient, would refer to Heart Team. If indications for CABG are clear, then the choice for SAVR concomitantly is clear. If not, I would tend to favor PCI (if indicated), then elective TAVR in this case. But I would be strongly influenced by opinion of Heart Team concensus and informed patient preference.
  • 5yr
    Agree that would cath prior to referral. Any coronary intervention that is percuteous could be done before, but usually access adequate after as well.
    Suspect TAVR would be performed, since repeat TAVR always an option in the future.
    Refer to the structural heart team coordinator, and then a team reviews the case.
  • 5yr
    I would discuss with the patient that he likely qualify for both TAVR and SAVR. Assuming he did not have a strong preference I would refer to heart team. In our institution it is a simple referral that “gets the ball rolling.” In this day and age we look for reasons not to do TAVR vs several years ago when TAVR was the treatment for the highest risk patients
  • 5yr
    As always this is why best practice is to have a multidisciplinary team develop a treatment approach for each patient that is individualized. In this patient, TAVR is likely, but if there is a concern for coronary access an approach using TAVR Which could allow this is important. Also, if he does need future valve surgery, valve in valve is becoming very mainstream.
  • 5yr
    I would of course allow the patient and surgeon/structural heart team to come to this decision mutually, but I'd be inclined to send him or her for SAVR at this point, as it's very likely they will need at least one more valve and I'd prefer to save the less invasive option for him or her when they are older. The risk of a single open heart surgery, particularly valve only, is quite low, particularly in a younger patient. The potential for implant to interfere with the coronary ostia would not be a huge factor in my decision making unless the patient already had a left main stent or multiple stents and known difficult root anatomy.
  • 5yr
    Obviously pt will undergo coronary angiography to assess coronary disease as part of evaluation. Unless patient has surgical CAD, suspect he will be good candidate for TAVR, with likely valve in valve for next procedure. Option to avoid sternotomy is highly motivating to avoid SAVR, even though TAVR forgoes option for very long lasting mechanical valve.
    I refer to interventionalists on heart team in my hospital….they keep me informed of workup and treatment decision.
  • 5yr
    Would prefer TAVR and wouldn’t be very concerned about future pci in future if w/u beg ( consider fast CT scan to r/o cad
    I refer to a heart team at a tertiary hospital and once they evaluate they generally call me to discuss
  • 5yr
    The patient is over the age of 65. I assume that the patient is low risk. I would likely recommend transcatheter aortic valve replacement with an Edwards valve to maintain coronary access. The only reason that I would recommend surgical aortic valve replacement would be if he has a small annulus that would prevent us from placing a 23 or 26 mm valve, which would preclude valve in valve TAVR in the future. I am a member of our heart team, so I cannot speak to the referral process, as I can't send patients elsewhere.
  • 5yr
    Not to young for TAVI would be candidate for valve in valve or second TAVI down the road.

Show More Comments