Choice of intervention for symptomatic severe calcific aortic stenosis*

SAVR: surgical aortic valve replacement; STS-PROM: Society of Thoracic Surgeons predicted risk of mortality; TAVI: transcatheter aortic valve implantation.
* Refer to UpToDate content regarding diagnosis and evaluation of symptomatic severe aortic stenosis.
¶ Examples of absolute contraindications to SAVR not captured by STS-PROM include porcelain aorta and hostile chest (chest conditions that make operation through sternotomy or thoracotomy prohibitively hazardous).
Δ Anatomic features that increase the risk of TAVI include severely calcified left ventricular outflow tract, low coronary ostia height, heavily calcified bicuspid aortic valve, or adverse aortic root (small sinus of Valsalva or small, calcified sinotubular junction).
◊ Clinical factors influencing the choice between TAVI and SAVR include the patient's values and preferences, age, estimated life expectancy with AVR, as well as concurrent conditions. Factors that favor SAVR include presence of another indication for cardiac surgery (eg, need for coronary artery bypass graft surgery), patient age <75 years old, patient characteristics favoring mechanical valve replacement (ie, age <55 plus no contraindication for anticoagulation), as well as anatomic features that increase the risk of TAVI (refer to Δ footnote). Factors that favor TAVI include feasibility of transfemoral TAVI, patient age >75 years old and presence of risk factors for SAVR (such as frailty, porcelain aorta, prior mediastinal irradiation or cirrhosis) that may not be captured by the STS-PROM score.
§ SAVR is preferred in this setting. In patients with a relative contraindication to SAVR, an individualized risk-benefit assessment of SAVR versus alternate access TAVI is performed. Examples of relative contraindications to SAVR not captured by STS-PROM include frailty, cirrhosis, and prior coronary artery bypass graft surgery with vulnerable graft location as assessed by computed tomography.