This patient should undergo surgical aortic valve replacement. Surgical aortic valve replacement is the only treatment of aortic stenosis associated with a survival benefit and durable symptom relief. Surgical aortic valve replacement is the treatment of choice for most patients with symptomatic severe aortic stenosis and is associated with low mortality rates for patients younger than 70 years (1%-3%).

Aortic valve repair is an option in a limited number of adult patients with aortic valve disease. In general, it is restricted to patients with aortic regurgitation and anatomically favorable aortic valve and root anatomy and can range from simple cusp plication to complex valve-sparing aortic root replacement. This patient has severe calcific aortic stenosis and a valve that is unlikely to be amenable to repair.

Balloon valvuloplasty, although important in the treatment of pediatric patients with severe aortic stenosis, has a more limited role in adults, either as a bridge to definitive treatment, to differentiate dyspnea symptoms in high-risk patients with comorbid conditions such as COPD, or to treat patients with calcific aortic stenosis with hemodynamic instability or decompensation. While balloon valvuloplasty is a potential consideration for this patient, the presence of significant aortic regurgitation is a contraindication. Improvement in aortic valve area from this procedure is modest, and many patients have residual severe aortic stenosis immediately after valvuloplasty. Balloon valvuloplasty would not be the best option for this patient.

Transcatheter aortic valve replacement (TAVR) is indicated for patients with severe symptomatic aortic stenosis who are considered unsuitable for conventional surgery because of severe comorbidities. Candidates for TAVR must be carefully selected. Surgical risk should be assessed objectively, such as by using the Society of Thoracic Surgeons adult cardiac risk score (STS score) (http://riskcalc.sts.org/STSWebRiskCalc273/de.aspx). Patients with an STS risk score of greater than or equal to 8% may be candidates for TAVR. In addition, TAVR is not approved in patients with concomitant valve disease (such as significant aortic regurgitation or mitral valve disease) and a bicuspid aortic valve. This patient has a bicuspid aortic valve and moderate aortic regurgitation; therefore, she would not be a candidate for TAVR.