Background
Aortic stenosis is the most common valvular heart disease in the elderly population, with a prevalence of approximately 3% in patients over 75 years old. The prognosis of symptomatic severe aortic stenosis is poor, with a 50% mortality rate at 2 years; therefore valve replacement is usually recommended once symptoms of shortness of breath, heart failure, or angina occur.
In the majority of patients, the aortic valve is trileaflet. Patients with severe aortic stenosis below the age of 65 usually have a congenital bicuspid aortic valve. In both cases, the aortic valve becomes progressively calcified with age and leaflet movement is restricted.
TAVR for aortic stenosis
Transcatheter aortic valve replacement (TAVR) has emerged as an alternative to surgical aortic valve replacement (SAVR) in patients with severe symptomatic aortic stenosis. The last decade has seen a steep rise in the number of TAVR procedures performed, as well as improvements in valve design, technology, and procedural techniques.
Decisions regarding the type of valve and approach to valve implantation are best made through a heart valve team and performed in a center with appropriate experience and infrastructure. In low-risk patients, the current American Heart Association/American College of Cardiology (AHA/ACC) guidelines recommend SAVR via a midline sternotomy. Patients at high and intermediate risk may have TAVR recommended ( Box 7.1 ). TAVR in low-risk patients is feasible, but requires further data on prosthesis durability before it is offered in younger patients.
| I | C | For patients considered for TAVR, a heart valve team, including experts in valvular heart disease, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery, should collaborate to provide optimal patient care |
| I | A | SAVR or TAVR is recommended for symptomatic patients with severe aortic stenosis (AS) and high risk for SAVR, depending on patient-specific procedural risks, values, and preferences |
| I | A | TAVR is recommended for symptomatic patients with severe AS and a prohibitive risk for SAVR who have a predicted post-TAVR survival greater than 12 months |
| IIa | B-R | TAVR is a reasonable alternative to SAVR for symptomatic patients with severe AS and an intermediate surgical risk, depending on patient-specific procedural risks, values, and preferences |
| III | B | TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS |
Assessment and risk stratification of patients
The Society of Thoracic Surgeons (STS) score and other factors may be used to stratify patients into low, intermediate, and high risk ( Table 7.1 ). The STS score is based on age, gender, comorbidities (including hypertension, peripheral arterial disease, cerebrovascular disease, diabetes, and lung disease), and immediate preoperative condition (including presence of cardiogenic shock and whether the patient currently has heart failure). Scores are best assessed using the online calculator found at http://riskcalc.sts.org/stswebriskcalc/ . The Euroscore uses similar criteria and is found at http://www.euroscore.org .
| Low risk |
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| Intermediate risk |
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| High risk |
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| Prohibitive risk |
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