01Purpose and principlesWhat the treatment does and how it fits into care.
A Heart Team combines clinical, imaging, interventional and surgical expertise to decide whether intervention will improve survival, symptoms or both. The correct question is not simply catheter versus surgery, but whether the valve is the main driver of disability and which strategy offers meaningful durable benefit.
Transcatheter procedures reduce surgical trauma but can bring paravalvular leak, vascular injury, coronary obstruction, pacemaker need and uncertain very-long-term durability. Surgery allows repair, annular/aortic work and combined procedures but carries sternotomy, bypass and recovery burdens.
Key points
- Symptoms, ventricular response and lesion severity drive intervention; age alone never establishes an indication.
- For severe aortic stenosis, NICE favours SAVR in people under 75 who are low surgical risk and TAVI in people 75 or older or at high surgical risk when both are suitable; anatomy, life expectancy and preference can change the choice.
- TAVI is offered when surgery is unsuitable and transfemoral anatomy is feasible; surgery remains important for bicuspid anatomy, aortopathy, endocarditis or disease needing concomitant CABG/other valve repair.
- Durable surgical mitral repair is preferred over replacement for suitable severe primary mitral regurgitation.
- Mitral transcatheter edge-to-edge repair (TEER) is an option for symptomatic severe primary MR when surgery is unsuitable and anatomy is suitable; secondary MR requires optimised HF therapy and specialist selection.
- Transcatheter tricuspid intervention is anatomy- and centre-dependent; NICE procedural governance and a specialist Heart Team are required.
- The intervention decision must include frailty, cognition, renal/lung disease, rehabilitation potential, expected survival, durability, pacemaker risk, access route and the person's priorities.
- A technically successful procedure still needs baseline imaging, antithrombotic planning, endocarditis advice and lifelong surveillance.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Exertional breathlessness, angina, presyncope/syncope or heart failure with severe valve obstruction warrants prompt intervention review.
Falling LVEF, progressive chamber enlargement, pulmonary hypertension or new AF may justify intervention before advanced symptoms.
Pulmonary oedema or shock after papillary-muscle/chordal rupture, endocarditis or aortic dissection needs emergency surgical/structural assessment.
Bicuspid valve, low coronary heights, small/large annulus, heavy LVOT calcification, aortic aneurysm or unsuitable access can redirect TAVI to surgery.
Severe frailty, irreversible organ failure, advanced dementia or symptoms dominated by non-cardiac disease require explicit benefit assessment, not automatic intervention.
Degenerated surgical or transcatheter bioprostheses may be suitable for valve-in-valve treatment, but coronary obstruction and residual-gradient risk must be modelled.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Comprehensive TTEFirst step - Why
- Confirm mechanism/severity and ventricular, pulmonary-pressure and multivalve consequences.
- Interpretation and limitations
- Reconcile discordant measures and flow state before intervention; repeat or add stress imaging if symptoms and resting data conflict.
- 02
TOE/3D echo - Why
- Define mitral/tricuspid leaflet anatomy, repairability, TEER grasping zone and endocarditis complications.
- Interpretation and limitations
- Anatomical suitability is procedural, not just severity-based.
- 03
ECG-gated CT - Why
- Size the annulus, assess calcification, coronary heights, aorta and vascular access for TAVI/valve-in-valve.
- Interpretation and limitations
- Unfavourable coronary or access anatomy may favour surgery or require protection/alternative access.
- 04
Coronary assessment - Why
- Identify CAD requiring PCI or CABG and map coronary anatomy before intervention.
- Interpretation and limitations
- Complex disease needing surgical revascularisation favours combined surgery; simple proximal disease may be treated percutaneously.
- 05
Frailty, cognition and functional assessment - Why
- Estimate recovery, independence and likely patient-valued benefit.
- Interpretation and limitations
- Risk scores omit important frailty and disability; severe irreversible limitation can make an anatomically feasible procedure futile.
- 06
Exercise testing, CMR or invasive haemodynamics when discordant - Why
- Reveal symptoms, quantify regurgitation/volumes or clarify gradients and pulmonary vascular disease.
- Interpretation and limitations
- Use to resolve a decision, not as routine duplication.
04Treatment approachPreparation, options, escalation and aftercare.
01ASSevere aortic stenosisFirst stepSymptoms or another guideline trigger for valve replacement after severity is confirmed.+
- 1Exclude a reversible high-flow or measurement explanation and document symptom/ventricular trigger.
- 2AlternativeIf surgery is unsuitable and transfemoral anatomy is suitable, offer TAVI; if TAVI is technically unsuitable, discuss alternative access versus palliation.
- 3If both are suitable, generally favour SAVR below 75 at low surgical risk and TAVI at 75 or above or high surgical risk, then modify for anatomy, durability, concomitant disease and preference.
- 4Choose SAVR when endocarditis, aortic surgery, complex CABG, another surgical valve procedure or anatomy unsuited to safe TAVI is present.
02Primary MRSevere primary mitral regurgitationSymptoms, LV trigger, pulmonary hypertension, new AF or another accepted intervention trigger.+
- 1Have an expert repair team define mechanism and probability of durable repair.
- 2If surgical risk is acceptable and durable repair is likely, choose surgical repair rather than replacement.
- 3If surgery is unsuitable and the person remains symptomatic with suitable anatomy, consider mitral TEER after Heart Team review.
- 4If neither repair nor TEER is likely to deliver benefit, optimise congestion/AF/HF care and revisit goals rather than performing a low-value procedure.
03Secondary MRSevere secondary mitral regurgitationPersistent symptoms despite optimised HFrEF and device therapy where indicated.+
- 1Optimise evidence-based HF medicines, volume status, rhythm and CRT eligibility before labelling MR refractory.
- 2If CABG or another cardiac operation is indicated, assess concomitant mitral surgery.
- 3If no surgical indication and anatomy/ventricular profile predicts benefit, consider TEER in a specialist multidisciplinary service.
- 4EscalationIf LV disease is too advanced for valve benefit, escalate advanced-HF or palliative care rather than treating MR as an isolated lesion.
04AftercarePost-intervention surveillanceAny surgical or transcatheter valve repair/replacement.+
- 1Before discharge, document procedural result, rhythm/conduction status, access/wound complications and antithrombotic regimen.
- 2Create a baseline TTE for future comparison and arrange valve-clinic review.
- 3Explain dental hygiene, infective-endocarditis symptoms, medicines, rehabilitation and when new dyspnoea/syncope/fever needs urgent review.
- 4EscalationEscalate an early rising gradient, new regurgitation, haemolysis, conduction change or heart failure for prosthetic/repair imaging rather than waiting for routine follow-up.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Aspirin after TAVI
75 mg by mouth once daily when there is no separate indication for oral anticoagulation; use clopidogrel 75 mg once daily if aspirin is not tolerated.Do not add routine oral anticoagulation or dual antiplatelet therapy solely for TAVI; reconcile recent PCI and bleeding risk.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- Document symptoms, NYHA class, frailty and the intervention goal before treatment so benefit can be judged afterwards.
- Monitor ECG/telemetry after TAVI for new conduction disease; delayed high-grade block requires urgent assessment.
- Check FBC, renal function and access/wound sites early after intervention and after any bleeding or contrast-associated injury.
- Use a predischarge/baseline TTE and subsequent valve-clinic imaging; compare gradients and regurgitation with that baseline.
- Review antithrombotic indication and duration at discharge and every transition of care to prevent accidental dual/triple therapy.
- Maintain lifelong clinical follow-up for every repaired or replaced valve, with earlier review for new symptoms, fever or embolic events.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Repair beats replacement only when durable
The advantage of mitral repair depends on expert anatomy selection and a durable result; a nominal repair with important residual MR is not a win.
TAVI age is a decision aid
The NICE 75-year split applies when both procedures are suitable; bicuspid aortopathy, coronary access, durability or patient goals may outweigh it.
Low-flow AS needs proof
A small valve area with a low gradient can reflect true severe stenosis or pseudo-severe disease; define flow and use stress echo/CT calcium when needed.
Valve-in-valve can trade one problem for another
A small surgical valve may leave a high residual gradient, and displaced leaflets can obstruct coronary ostia.
Futility is a clinical conclusion
A procedure is not beneficial merely because it is technically possible; link expected survival and functional gain to the person's priorities.
08Common pitfallsFrequent interpretation and management errors.
- 01
Choosing TAVI or surgery from age alone before confirming an intervention indication and anatomy.
- 02
Referring secondary MR for TEER before optimising HFrEF therapy and CRT eligibility.
- 03
Assuming all severe primary MR is repairable outside an expert repair service.
- 04
Ignoring post-TAVI conduction disease or coronary-access implications in a younger person.
- 05
Failing to establish a post-procedure baseline echo and antithrombotic stop dates.