Multimodality Imaging and Heart Team Decision-Making for Transfemoral TAVI in an 85-Year-Old Patient With Severe Aortic Stenosis

Background: Severe symptomatic aortic stenosis (AS) is associated with substantial morbidity and mortality if left untreated. The choice between surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) should be individualized according to age, surgical risk, comorbidities, frailty, anatomical characteristics, feasibility of transfemoral access, life expectancy, expected quality of life, and patient preferences. Case Presentation: An 85-year-old man with type 2 diabetes mellitus treated with oral medication and severe chronic obstructive pulmonary disease (COPD) was admitted for progressive exertional dyspnea and angina occurring with minimal exertion. He also reported episodes of presyncope without syncope. He was in New York Heart Association (NYHA) functional class III. Physical examination revealed an irregular cardiac rhythm and a harsh systolic ejection murmur associated with abolition of the second heart sound. Electrocardiography demonstrated atrial fibrillation with left ventricular hypertrophy. Transthoracic echocardiography showed very severe aortic stenosis, with an indexed aortic valve area of 0.52 cm²/m² and preserved left ventricular ejection fraction (LVEF) of 56%. No pulmonary hypertension or right ventricular dilatation was observed. Laboratory investigations revealed moderate renal impairment, with a creatinine level of 13 mg/L and an estimated creatinine clearance of 45 mL/min. Hemoglobin was 11 g/dL. Pulmonary function testing demonstrated severe obstructive ventilatory impairment. improvement in symptoms and functional capacity. Multidetector computed tomography (CT) demonstrated extensive calcification of the aortic valve, a tricuspid valve with a pseudobicuspid appearance due to calcification, an annular area of 634.6 mm² and a perimeter of 90.6 mm. Coronary ostial height was considered satisfactory. Iliofemoral anatomy was suitable for transfemoral access, with vessel diameters ranging from 8.0 to 10.2 mm and minimal tortuosity. The coronary calcium score was markedly elevated at 2452 Agatston units. Because coronary CT assessment was limited by blooming and motion artifacts, invasive coronary angiography was performed and demonstrated diffuse coronary calcification without significant obstructive coronary artery disease. Following multidisciplinary Heart Team assessment, transfemoral TAVI was selected because of the patient’s advanced age, severe COPD, moderate renal impairment, symptomatic status, favorable valve anatomy, and suitable transfemoral access. The procedure was successfully performed without major complications. The patient’s subsequent clinical course was favorable, with marked Conclusion: This case illustrates the importance of individualized Heart Team decision-making in very elderly patients with symptomatic severe AS. In an 85-year-old patient with severe COPD, moderate renal impairment, diabetes mellitus and atrial fibrillation, favorable anatomical characteristics and transfemoral access supported TAVI as an appropriate treatment strategy. The patient’s subsequent functional recovery highlights the importance of considering quality of life and restoration of independence in addition to conventional operative risk scores.