Unrevascularized CAD in Patients Undergoing TAVR

An 84-year-old female patient presents with progressive worsening of dyspnea on exertion and occasional episodes of lightheadedness. The patient reports that over the last 12 months, her symptoms have progressively worsened, and she is now able to walk only around the house. Her past medical history is significant for long-standing hypertension, chronic kidney disease (stage II), anemia of chronic disease, and transient ischemic attack (TIA). On examination, the patient is a thin, frail woman in no apparent distress at rest. Auscultation reveals a late-peaking ejection systolic murmur. An electrocardiogram shows evidence of left ventricular hypertrophy. An echocardiogram reveals normal left ventricular systolic function, severe degenerative aortic stenosis (AS), mean transvalvular gradient of 48 mm Hg, and calculated aortic valve area of 0.7 cm2. Dense calcification of the ascending aorta is noted on computed tomography scan (porcelain aorta). The patient undergoes coronary angiography; pertinent findings are shown here.

A heart team discussion was held, and the patient was deemed high risk for surgical aortic valve replacement (SAVR) due to overall frailty, severe calcification of ascending aorta, and prior TIA.

What is the next step in management of this patient?

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