Decision Making for TAVR vs SAVR in Severe Aortic Stenosis

Introduction to Decision Making

The American College of Cardiology recommends that the decision between TAVR and SAVR for a 72-year-old patient with severe aortic stenosis be based on surgical risk assessment (STS-PROM score), frailty status, and anatomic suitability for transfemoral access 1, 2, 3

If significant coronary artery disease requiring surgical revascularization (CABG) is present, the European Heart Journal indicates SAVR is preferred as it allows concurrent CABG during the same operation 4, 3
The European Heart Journal suggests that if coronary disease is absent or amenable to percutaneous coronary intervention (PCI), a risk-based algorithm should be used to decide between TAVR and SAVR 2

For low surgical risk (STS-PROM <4%, no frailty, no major comorbidities), the American College of Cardiology recommends SAVR due to superior long-term valve durability data 1, 5, 4, 3
For intermediate risk (STS-PROM 4-8%, mild frailty, or 1 major organ compromise), the American College of Cardiology and European Heart Journal suggest either TAVR or SAVR is appropriate after shared decision-making about valve durability versus procedural recovery 1, 2, 3
For high risk (STS-PROM >8%, moderate-severe frailty, or ≥2 major organ compromises), the American College of Cardiology and European Heart Journal recommend TAVR as the preferred approach if transfemoral access is anatomically feasible 1, 2, 4

The American College of Cardiology recommends proceeding with TAVR if transfemoral access is feasible with adequate iliofemoral vessel diameter and minimal calcification 1
The European Heart Journal suggests that TAVR is favored if transfemoral access is suitable and the patient prefers faster recovery 2, 4

The American College of Cardiology and European Heart Journal indicate that patient preference for minimally invasive approach with faster recovery, oxygen-dependent lung disease, dialysis dependence, cirrhosis with MELD score >14, and prior cardiac surgery with hostile mediastinum favor TAVR 1, 2
The American College of Cardiology suggests that patient age 72 with expected longevity >15 years and desire for maximum valve durability favor SAVR 5, 3

The American College of Cardiology warns against relying solely on STS-PROM score, as it underestimates risk in elderly patients and does not account for frailty, disability, or cognitive function 8
The American College of Cardiology and European Heart Journal advise against ignoring frailty assessment, as moderate-severe frailty shifts decision toward TAVR even with lower STS scores 1, 5

The American College of Cardiology recommends that all decisions involve a multidisciplinary Heart Valve Team including interventional cardiologists, cardiac surgeons, imaging specialists, anesthesiologists, and heart failure specialists 1, 5, 9