Management of Severe Aortic Stenosis in Late 60s or Older with Reduced Ejection Fraction

Age-Based Decision Algorithm

For patients ≥80 years old, the European Society of Cardiology recommends TAVR over surgical aortic valve replacement (SAVR) 1, 2, 3
For patients ≥80 years old, TAVR is definitively recommended over SAVR, assuming transfemoral access is anatomically feasible 1, 2, 4
Meta-analysis of 7 major RCTs demonstrated TAVR reduces 2-year all-cause mortality regardless of STS risk score in patients ≥80 years old 5
For patients 65-80 years old, either TAVR or SAVR is appropriate, with the decision based on surgical risk stratification 1, 2, 4
If STS-PROM ≥8% or EuroSCORE II >8%, the American College of Cardiology recommends TAVR over SAVR 1, 2, 6

The European Heart Society states that high-risk features such as porcelain aorta or hostile chest anatomy strongly favor TAVR over SAVR 1, 6
Moderate-to-severe frailty, oxygen-dependent lung disease, dialysis dependence, and cirrhosis with MELD score >14 are conditions that favor TAVR over SAVR 1, 6
Multiple organ system compromise (≥2 major organs) also favors TAVR over SAVR 6

Adequate iliofemoral vessel diameter with minimal calcification is required for TAVR, as recommended by the Journal of the American College of Cardiology 4, 6
Aortic root anatomy must be evaluated for excessive calcification or annulus size out of range for available devices, as stated by the European Heart Journal 1, 2

All decisions must involve a Heart Valve Team, including interventional cardiologists, cardiac surgeons, cardiac imaging specialists, anesthesiologists, heart failure specialists, and geriatric assessment when appropriate, as recommended by the European Heart Journal and the American College of Cardiology 1, 2, 5, 6
The team evaluates surgical risk, frailty, anatomic suitability, patient preferences, and expected longevity versus valve durability 1, 2, 4

If significant coronary disease requires surgical revascularization (CABG), SAVR + CABG is preferred over TAVR, as stated by the European Heart Journal 7, 6
If coronary disease is amenable to percutaneous coronary intervention (PCI), PCI can be performed before TAVR, as recommended by the European Heart Journal 7