90-Year-Old With Severe Aortic Stenosis & Complete Heart Block: A Staged Heart Team Approach

A 90-Year-Old With Severe Aortic Stenosis, Severe LV Dysfunction and Complete Heart Block — A Staged Heart Team Approach

I am pleased to share a challenging structural heart case managed at Max Shalimar Bagh, highlighting the importance of individualized Heart Team decision-making in a frail nonagenarian with complex structural and electrical heart disease.

Presentation

A 90-year-old gentleman, with a history of previous PTCA, presented with complete heart block (CHB).

Echocardiography demonstrated:

* Severe degenerative aortic stenosis
* Peak gradient: 109 mmHg
* Mean gradient: 62 mmHg
* LVEF: 30%

The patient had significant additional risk factors, including:
* Previous CVA
* Chronic kidney disease
* Frailty
* Advanced age

The reported STS predicted operative mortality was approximately 10%.

The Clinical Challenge

This was not simply a case of severe aortic stenosis.

The patient had severe AS + severe LV dysfunction + complete heart block, in the setting of frailty, previous cerebrovascular disease and CKD.

The combination created a challenging balance between:

Electrical instability → requiring definitive pacing and

Severe fixed LV outflow obstruction → requiring definitive valve intervention.

The case was therefore discussed within the multidisciplinary Heart Team, with consideration of the patient’s surgical risk, frailty, comorbidities, ventricular function and overall clinical goals.

Our Strategy — A Staged Approach

Rather than attempting to address both problems simultaneously, we adopted a sequential strategy.

Step 1 — CRT-D implantation

In view of complete heart block and LVEF of 30%, CRT-D implantation was performed to establish reliable ventricular pacing while providing cardiac resynchronization in the setting of significant LV systolic dysfunction.

Step 2 — TAVI

Following stabilization, the patient underwent transcatheter aortic valve implantation (TAVI) with a 27-mm Navitor valve.

Both procedures were successfully completed, and the patient tolerated the staged strategy well.

Why is this case interesting?

This case illustrates several important principles in contemporary structural heart practice:

1. Complex patients require multidisciplinary decision-making.

When severe AS coexists with LV dysfunction and complete heart block, structural and electrophysiological considerations cannot be viewed in isolation.

2. The sequence of interventions can be an important part of the strategy.

Establishing an appropriate pacing and resynchronization strategy before valve intervention was considered appropriate in this particular clinical context.

3. Chronological age should not be considered in isolation.

In a nonagenarian, treatment decisions should incorporate frailty, comorbidities, functional status, anatomy, procedural risk and patient goals.

4. Risk scores are only one part of the assessment.

An STS-PROM of approximately 10% provided an important estimate of surgical risk, but the Heart Team assessment also incorporated factors such as frailty, prior CVA, CKD and severe LV dysfunction.

Take-Home Message

A frail 90-year-old with severe AS, LVEF 30% and complete heart block represents a particularly challenging clinical scenario.

This case demonstrates how a staged, multidisciplinary transcatheter strategy integrating CRT-D and TAVI can be considered in carefully selected high-risk patients.

The question in a very elderly patient is not simply “How old is the patient?” — but “What is the patient’s physiological reserve, procedural risk, anatomy, functional status and treatment goal?”

A rewarding example of individualized Heart Team decision-making.

Kudos to the entire multidisciplinary team at Max Shalimar Bagh.

#TAVI #TAVR #StructuralHeart #AorticStenosis #CRT #CRTD #HeartTeam #Electrophysiology #InterventionalCardiology #HeartFailure #Frailty #Nonagenarian #StructuralIntervention