Severe Aortic Stenosis, Porcelain Aorta, and a Proximal LAD Lesion: SAVR plus CABG or TAVR plus PCI?

The dominant feature is the porcelain ascending aorta, not the calculated risk scores alone. A circumferential calcified aorta makes cross-clamping and aortotomy hazardous and increases stroke risk during SAVR; this pushes the balance toward TAVR even though STS 6.4% and EuroSCORE II 5.2% are only intermediate. The frailty markers also matter: gait speed >6 seconds, albumin <35 g/L, and MMSE 24/30 identify a patient who may survive surgery but recover slowly and lose independence. The 75% proximal LAD lesion is important because hypotension or rapid pacing during TAVR can cause ischemia in a large territory; it should be revascularized, usually with a drug-eluting stent, before or during the TAVR admission. The 55% RCA lesion does not require intervention. Access is the main caveat: 5.2 mm right and 4.8 mm left iliofemoral vessels are borderline for standard TAVR sheaths. I would recommend TAVR with prior LAD PCI, but only after CT access planning confirms a low-profile sheath can be used or an alternative access route is feasible. If access is inadequate, the fallback is not automatically SAVR; it is a hybrid or alternative-access TAVR discussion, because porcelain aorta still makes surgery high risk.

Because she is symptomatic but not in cardiogenic shock, I would stage PCI first with a drug-eluting stent to the proximal LAD, then proceed to TAVR within days to a few weeks rather than waiting months. This treats the ischemia-prone territory before rapid pacing and hypotension. The trade-off is bleeding: recent PCI commits her to dual antiplatelet therapy, while TAVR alone would usually allow single antiplatelet therapy. In a frail 79-year-old, I would use aspirin plus a P2Y12 inhibitor for the shortest defensible period, commonly 1–3 months, then drop to single antiplatelet therapy unless there is another indication. I would avoid triple therapy unless she has atrial fibrillation requiring anticoagulation. Access remains the limiting issue: a 5.2 mm right femoral artery may accept a low-profile 14F sheath, but calcification and tortuosity can cause rupture or access failure. CT with iliofemoral reconstruction should guide the side and sheath choice. If transfemoral access is not safe, transaxillary, transcarotid, or transcaval access are alternatives, each with specific risks. The PCI and TAVR team should agree on a single access plan before starting.

I would frame the choice in terms of what matters to her: avoiding a long ICU stay and maintaining independence. TAVR offers faster recovery and avoids aortotomy and cross-clamp in a porcelain aorta, but it carries a periprocedural stroke risk of roughly 3–5%, a pacemaker risk that depends on valve type and can exceed 10% with self-expanding valves, and a small risk of vascular injury or access failure. SAVR with CABG avoids some TAVR-specific risks but exposes her to a high stroke risk from aortic manipulation, prolonged ventilation, and a longer recovery, which is particularly important given her frailty and solitary living situation. I would not quote a single number as decisive. I would explain that her porcelain aorta and frailty make surgery higher risk than the STS score suggests, and that TAVR is likely her better option if access is feasible. I would also discuss the possibility of a pacemaker and the need for close follow-up, and confirm that she understands that TAVR is not risk-free. The final decision should be documented with the heart team and her family or advocate present.