The mechanism by which bal- loon dilation modestly reduces the severity of stenosis in older patients is fracture of calcific deposits within the valve leaflets and, to a minor degree, stretching of the annulus and separa- tion of the calcified or fused commissures. Immediate hemodynamic results include a Table 14. A Simplified Framework With Examples of Factors Favoring SAVR, TAVI, or Palliation Instead of Aortic Valve Intervention Favors SAVR Favors TAVI Favors Palliation Age/life expectancy* Younger age/longer life expectancy Older age/fewer expected remaining years of life Limited life expectancy Valve anatomy BAV Subaortic (LV outflow tract) calcification Rheumatic valve disease Small or large aortic annulus Calcific AS of a trileaflet valve Prosthetic valve preference Mechanical or surgical bioprosthetic valve preferred Concern for patient prosthesis mismatch (annular enlargement might be considered) Bioprosthetic valve preferred Favorable ratio of life expectancy to valve durability TAVI provides larger valve area than same size SAVR Concurrent cardiac conditions Aortic dilation Severe primary MR Severe CAD requiring bypass grafting Septal hypertrophy requiring myectomy AF Severe calcification of the ascending aorta ( porcelain aorta) Irreversible severe LV systolic dysfunction Severe MR attributable to annular calcification Noncardiac conditions Severe lung, liver, or renal disease Mobility issues (high procedural risk with sternotomy) Symptoms likely attributable to noncardiac conditions Severe dementia Moderate to severe involvement of 2 other organ systems Frailty Not frail or few frailty measures Frailty likely to improve after TAVI Severe frailty unlikely to improve after TAVI Estimated procedural or surgical risk of SAVR or TAVI SAVR risk low TAVI risk high TAVI risk low to medium SAVR risk high to prohibitive Prohibitive SAVR risk (>15%) or post- TAVI life expectancy <1 y Procedure-specific impediments Valve anatomy, annular size, or low coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI Previous cardiac surgery with at-risk coronary grafts Previous chest irradiation Valve anatomy, annular size, or coronary ostial height precludes TAVI Vascular access does not allow transfemoral TAVI Goals of Care and patient preferences and values Less uncertainty about valve durability Avoid repeat intervention Lower risk of permanent pacer Life prolongation Symptom relief Improved long-term exercise capacity and QOL Avoid vascular complications Accepts longer hospital stay, pain in recovery period Accepts uncertainty about valve durability and possible repeat intervention Higher risk of permanent pacer Life prolongation Symptom relief Improved exercise capacity and QOL Prefers shorter hospital stay, less postprocedural pain Life prolongation not an important goal Avoid futile or unnecessary diagnostic or therapeutic procedures Avoid procedural stroke risk Avoid possibility of cardiac pacer *Expected remaining years of life can be estimated from US Actuarial Life Expectancy tables. 