Severe Aortic Stenosis with a Small Annulus and Frailty
An 84-year-old woman with severe symptomatic aortic stenosis (indexed aortic valve area 0.35 cm²/m², mean gradient 42 mmHg, peak velocity 4.2 m/s) is evaluated for aortic valve replacement. She has COPD on home oxygen, prior CABG 12 years ago, and frailty (gait speed slow, 5-meter walk >6 seconds). STS score is 9.8% for surgical AVR. CT shows an annulus perimeter of 68 mm (area ~360 mm²) with moderate calcification and iliofemoral access vessels of 5.0 mm minimum diameter. Coronary angiography shows patent grafts. She lives independently and wishes to avoid a long recovery.
1. Which valve intervention would you recommend, and how do you weigh TAVR versus SAVR?
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She has severe, symptomatic AS with intermediate-high surgical risk (STS 9.8%), frailty, prior CABG, and COPD. Current guidelines support TAVR for intermediate and high surgical risk, and increasingly for low risk in selected patients.
- TAVR is favored here: her STS score, frailty, prior sternotomy, and COPD increase surgical risk, and she prioritizes rapid recovery.
- Access: iliofemoral vessels of 5.0 mm are borderline for transfemoral TAVR (most current valves need ≥5.0–5.5 mm). Evaluate with CT for tortuosity, calcification, and sheath compatibility; consider a smaller-profile valve or alternative access (transapical, transcarotid, transaxillary) if transfemoral is not feasible.
- Annulus: 68 mm perimeter (~360 mm²) is small; choose a valve size and type that avoids patient-prosthesis mismatch. Self-expanding or balloon-expandable valves can both be used; sizing by CT is critical.
- Frailty should not automatically exclude her, but it informs shared decision-making and rehabilitation planning.
2. What pre-procedural planning steps are essential, and what complications do you counsel her about?
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Planning:
- CT angiography of the aortic root, annulus, and iliofemoral access; measure annulus perimeter/area, coronary heights, and calcium distribution.
- Echocardiography to confirm severity and assess LV function, MR, and pulmonary pressures.
- Coronary evaluation: grafts are patent; assess risk of coronary obstruction, especially with a small annulus and low coronary heights.
- Multidisciplinary heart team review and shared decision-making.
Counseling:
- Vascular complications (access site injury, bleeding) - highest with borderline iliofemoral diameter.
- Stroke (1–3%), paravalvular leak, pacemaker requirement (higher with self-expanding valves), coronary obstruction, annular rupture, and AKI.
- Mortality risk individualized to her STS score and frailty.
- Post-procedure: DAPT or single antiplatelet depending on valve and bleeding risk; follow-up echo.
3. How would you manage her antithrombotic therapy after TAVR given her age and bleeding risk?
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- Default: aspirin 75–100 mg daily indefinitely plus clopidogrel 75 mg daily for 3–6 months after TAVR, then aspirin alone. For patients at high bleeding risk (age, frailty, COPD), single antiplatelet therapy may be considered.
- If she has AF or another indication for anticoagulation, use an anticoagulant plus a short course of antiplatelet therapy, then anticoagulant alone.
- Avoid triple therapy unless there is a compelling reason (recent PCI with a high-risk stent).
- Monitor for bleeding, especially GI bleeding; consider a PPI.
- Do not routinely use DOACs after TAVR for valve thrombosis prophylaxis unless there is another indication; the evidence does not support routine DOAC use for this purpose.