Valvular Heart Disease — Written Clinical Reasoning

SAQ 1 — Integrated Management (20 marks, 30 minutes)

Prompt: Outline your integrated assessment and management plan for this patient, including the diagnostic work-up, the intervention decision and its justification, comorbidity optimisation, and follow-up. Justify each decision with reference to evidence. ^[1]

Model Answer

Problem list (4 marks):

1. Severe symptomatic calcific aortic stenosis (Stage D, mean gradient >40 mmHg, AVA 0.7 cm²) — the primary problem requiring intervention
2. Moderate functional MR and TR — likely secondary to the AS-related afterload and LA/LV remodelling; expected to improve after AVR
3. Permanent AF on appropriate anticoagulation (apixaban)
4. CKD stage 3a (eGFR 48) and type 2 diabetes — influence procedural contrast and perioperative management
5. Mild ascending aortic dilatation (39 mm) — below surgical threshold but needs surveillance
6. Frailty / functional assessment pending — influences SAVR vs TAVI
7. Polypharmacy and comorbidity (hypertension, dyslipidaemia) ^[1]

Diagnostic work-up to confirm severity and plan intervention (4 marks): ^[1]

• Confirm severe AS on current echo (already established: AVA 0.7 cm², mean gradient 52 mmHg, peak velocity 4.8 m/s). The echo shows severe AS with preserved EF — no need for dobutamine stress echo (reserved for low-flow low-gradient AS).
• Assess surgical risk and anatomy: STS-predicted mortality; frailty assessment; CT aortogram and annulus sizing for TAVI planning; assess femoral access and iliofemoral vessels.
• Coronary angiography (or CT coronary angiography if TAVI route likely) to exclude concurrent coronary artery disease that might require PCI (around TAVI) or CABG (with SAVR).
• TOE only if MR severity or mechanism is uncertain and would change management; otherwise TTE is sufficient.
• Baseline bloods, ECG (already in AF — note baseline conduction for pacing risk post-TAVI), and pulmonary function if SAVR is contemplated. ^[1]

Intervention decision — TAVI vs SAVR (6 marks): ^[1]

Refer to the heart team. Recommend transfemoral TAVI based on:

• Age (78 years) — the durability uncertainty of TAVI over 15+ years is less relevant.
• Frailty and comorbidity (CKD, diabetes, hypertension) — raise surgical risk.
• The evidence: PARTNER 3 (balloon-expandable, PMID 30883058) showed TAVI was non-inferior (1-year superior) to SAVR in low-risk patients; CoreValve US High Risk (self-expanding, PMID 24678937) showed TAVI superior to SAVR in high-risk patients. An intermediate-risk 78-year-old with frailty and CKD sits where TAVI is favoured. ^{[1] [2]}
• Aortic annulus and femoral access are the deciding anatomical factors (pending CT). ^[1]

SAVR would be preferred if: concomitant significant CAD needing CABG; unfavourable TAVI anatomy (bicuspid with heavy calcification, annulus unsuitable, hostile femoral access); or the patient's life expectancy exceeds ~15 years and valve durability is a priority. Neither applies strongly here. ^[1]

The mild ascending aortic dilatation (39 mm) is below the threshold for intervention (≥5.5 cm, or ≥5.0 cm with risk factors) and will be surveilled. ^[1]

Comorbidity optimisation (4 marks): ^[1]

• AF/anticoagulation: he is appropriately anticoagulated on apixaban for non-valvular AF. After TAVI, anticoagulation continues for AF; the valve team will manage peri-procedural interruption (typically stop apixaban ~48 h pre-procedure, resume once haemostasis secure). Note: apixaban is fine for native-valve AF, but DOACs are never used in mechanical valves (he will receive a bioprosthetic TAVI valve, so apixaban remains appropriate).
• CKD: minimise contrast during CT and TAVI; pre-procedural hydration; consider the contrast-sparing protocol. eGFR 48 is acceptable for TAVI but raises the risk of contrast-induced AKI.
• Diabetes: optimise glycaemic control peri-procedurally; SGLT2i has cardiovascular and renal benefit and should be continued (hold on the morning of procedure per local protocol). Consider switching gliclazide if hypoglycaemia risk.
• Blood pressure: continue perindopril; stop amlodipine if it adds to polypharmacy without clear benefit; control hypertension to reduce afterload and aortic growth.
• Prophylaxis: a TAVI valve is prosthetic material — ACC/AHA and ESC classify prosthetic valves (including TAVI) as high-risk, so amoxicillin 2 g PO single dose 30–60 min before invasive dental procedures is indicated (NICE does not routinely recommend prophylaxis — note the regional variation). ^[4]

Communication, follow-up and surveillance (2 marks): ^[1]

• Shared decision-making: explain SAVR vs TAVI (recovery time ~1 week vs 4–6 weeks; pacemaker risk ~15–20% for self-expanding, ~6% balloon-expandable; durability uncertainty at >8 years); clarify goals of care given frailty; involve family.
• Post-TAVI: baseline echo; ECG monitoring for conduction disease (a new LBBB or high-degree block may need pacemaker); surveillance echo at 30 days, 12 months, then annually.
• Ascending aorta surveillance echo/CT annually.
• Endocarditis prophylaxis education and good oral hygiene.
• Advance care planning appropriate given age and comorbidity. ^[1]