77-Year-Old With Symptomatic Aortic Stenosis
A 77-year-old female patient presents with progressively worsening dyspnea on exertion for the past year. She is symptomatic after walking half a block and has orthopnea, paroxysmal nocturnal dyspnea, and increasing lower extremity edema. She reports no chest pain or syncope. Her history is notable for prior coronary artery bypass surgery and hypertension. She is on optimal medical therapy, and her blood pressure is controlled. On exam, she has a harsh mid-peaking systolic murmur at the base, clear lung fields, and bilateral lower extremity pitting edema. Her B-type natriuretic peptide is 224 pg/mL. A transthoracic echocardiogram (TTE) shows a preserved left ventricular ejection fraction (LVEF) of 65%, diastolic dysfunction, and a calcified aortic valve (AV). Accompanied Doppler findings are outlined in Figure 1. Coronary angiography shows patent grafts and no obstructive disease. Invasively, her left ventricular end-diastolic pressure is 28 mmHg, and mean AV gradient is 33 mmHg. Despite judicious blood pressure control and diuresis, she remains symptomatic.
What is the most reasonable next step?