Physicians debate best management strategy for patient with severe aortic stenosis

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In a new Annals ‘Beyond the Guideline’s feature, a cardiologist and a cardiothoracic surgeon debate the risks and benefits of transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) for a patient with severe symptomatic aortic stenosis who is at low risk for surgical death. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.

Aortic stenosis is common among the elderly and severe symptomatic disease is typically fatal without intervention. Surgical aortic valve replacement (SAVR) was the standard of care until transcatheter aortic valve replacement (TAVR) was shown to have lower mortality rates in patients at the highest surgical risk. Recent recommendations suggest that TAVR may have benefits for patients at intermediate risk, as well. Whether or not these benefits extend to low-risk patients is a subject of debate.

BIDMC Grand Rounds discussants, Suzanne J. Baron, MD, MSc, an interventional and structural cardiologist as well as the Director of Interventional Cardiology Research at Lahey Hospital and Medical Center, Burlington, Mass., and Tsuyoshi Kaneko, MD, Surgical Director of the Structural Heart Program at Brigham and Women’s Hospital recently debated the case of a 62-year old man with symptomatic aortic stenosis and several comorbid conditions yet considered at low risk for surgical death.

In their assessment, both Drs. Baron and Kaneko recommend CT imaging as a next step to determine the patient’s candidacy for TAVR. If the patient met anatomical criteria, Dr. Baron would engage the patient in a deliberate, shared decision-making process to ensure that his values drive an informed choice between TAVR and SAVR. Because the patient is young and very likely to need a second valve procedure sometime in the future, Dr. Kaneko would work with the heart team to highlight the durability and subsequent valve replacement challenges with TAVR. Both discussants agree that the patient is likely to have a good outcome whether he chooses TAVR or SAVR.

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