How do you approach the management of aortic stenosis in an elderly, frail patient with multiple comorbidities who is symptomatic but considered high risk for surgical aortic valve replacement?

In an older patient with severe aortic stenosis (AS) who is not a candidate for surgery, there are 3 treatment options – TAVR, balloon aortic valvuloplasty (BAV), and medical management.

In the original PARTNER trial, 358 patients with severe AS who, in the judgement of at least 2 cardiac surgeons, w...

Elderly and Frail are key descriptors here. Most of these patients have minimal benefit from these procedures. Although we we maybe motivated to do something rather nothing, over many years of practice I am more prone to referring these patients to palliative care or hospice.

Just because we can doe...

I suppose although he is elderly and frail but symptomatic meaning the patient can ambulate? We don’t really have enough information on the patient’s history, physical capabilities, and comorbid conditions. As well as the nature of his symptoms (Is it angina, syncope, or heart failure) to give a rea...

What are the benefits of a procedure?

1. Prolong life
2. Avoid hospitalizations
3. Improve quality of life (QOL). Symptom amelioration
4. Prevent CHF??
5. Co-morbidity reduction

Truth be told, many very elderly patients have sedentary lifestyles and don't need the purported boost a TAVR may give.

In other words,...

TAVR, followed by cardiac rehabilitation, is a reasonable approach in this setting.

Certainly, in frail elderly patients, symptoms should guide treatment and possible TAVR. Cardiac MRI is something I have not done in general, but maybe a reasonable tool to help decide on intervention or not.

This difficult question, or a similar scenario, comes up not infrequently in my practice. I am humbled by my inability to reliably predict outcomes in this patient population. Some patients make remarkable recoveries and return to a relatively normal life, while others struggle and develop a myriad ...

A detailed discussion regarding both prognosis without intervention, as well as procedural risks in the setting of intervention, is vital in these cases. Additionally, though the patient may have technically have "symptomatic severe AS", the symptoms may actually be mild and tolerable.