You are asked to consult on a 93-year-old man with aortic stenosis (AS) who has been admitted to the hospital with chest pain and shortness of breath. He reports these symptoms on walking less than one block for the last two weeks, and feels that these symptoms have recently been limiting his daily activities. He was previously able to independently perform his activities of daily living including bathing, dressing, transferring, preparing meals and going to the restroom himself. His comorbidities include obesity, hypertension, hyperlipidemia, previous stroke with no major residual deficits, diabetes mellitus type 2, obstructive sleep apnea, and stage 3 chronic kidney disease. He lives with his son and daughter-in-law who are his primary caregivers and are very involved in his care.

Negative History: He has no history of coronary artery disease, valve surgery, peripheral vascular disease, hemodialysis, or immunosuppression.

Medications: Aspirin 81 mg daily, metoprolol succinate 50 mg daily, insulin, and atorvastatin 40 mg daily.

Vitals:
Height – 69"
Weight – 215 lbs
Heart Rate – 62 bpm
Blood Pressure – 124/62 mm Hg
Oxygen Saturation – 100% on room air

Physical Exam:
General Appearance – Pleasant, African American male, sitting comfortably and in no acute distress.
Neck – No jugular venous distention, delayed upstroke of carotid pulse.
Cardiovascular – Regular rhythm, soft first heart sound, III/VI late peaking crescendo decrescendo murmur heard best in the right second intercostal space with radiation to both carotids, soft A2 component, no gallops.
Extremities – Normal pulses bilaterally, no edema.
Neurological – He is oriented to person, place, time, and situation.

Grip strength (measured using a dynamometer in dominant hand): 30 kg
Gait speed (Time taken to walk 5 meters at a comfortable pace): 6 seconds

Laboratory Data:
B-Natriuretic Peptide (BNP) – 386 pg/mL
Creatinine – 2.1 mg/dL
White Blood Cell – 6.8 K/uL
Hemoglobin – 11.3 g/dL
Hematocrit – 33%
Platelet Count – 203 K/uL
Albumin – 3.7 g/dl
Hemoglobin A1c – 7.2%
Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were within normal limits.

EKG: Sinus rhythm, left ventricular hypertrophy (LVH).

Transthoracic Echocardiogram: Left ventricular ejection fraction (LVEF) is found to be 60% with no regional wall motion abnormalities noted. Moderate concentric LVH with normal left ventricular (LV) size. Trileaflet calcified aortic valve with severe AS with mean gradient of 55 mm Hg, peak velocity of 4.8 m/sec and aortic valve area of 0.9 cm². Mild aortic regurgitation. Moderate mitral regurgitation with enlarged left atrium. Normal right ventricular size and function, mild-moderate tricuspid regurgitation with pulmonary arterial systolic pressure of 45-50 mm Hg. No pericardial effusion noted. Increased filling pressures.

Cardiac Catheterization: Angiography shows right dominant coronary anatomy with 40% stenosis of the mid left anterior descending artery and 30% stenosis of the proximal right coronary artery.

His case is reviewed by two cardiac surgeons. The aortic valve is felt to be amenable to high-risk surgical aortic valve replacement; however, his Society of Transthoracic Surgeons (STS) Surgical Risk Scores for isolated surgical aortic valve replacement are elevated as follows:

Risk of Mortality: 10.30%
Morbidity or Mortality: 49.80%
Long Length of Stay: 36.58%
Permanent Stroke: 8.80%
Prolonged Ventilation: 33.45%
Renal Failure: 34.03%
Reoperation: 18.67%

After discussion with the surgeons and his family, the patient is worried about the risk of open heart surgery as well as high morbidity associated with surgical aortic valve replacement (SAVR) based on his STS scores. He requests consideration for a less invasive option (TAVR) which he has recently heard about from some of his friends.