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← Cardiology indexChapter sections
Purpose and principlesIndications, selection and cautionsAssessment before treatmentTreatment approachRegimens, contraindications and interactionsComplications, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Transcatheter and surgical valve intervention

Cardiology · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Time-critical presentation

Acute severe mitral or aortic regurgitation with pulmonary oedema or shock, an obstructed prosthesis, or decompensated critical stenosis requires monitored admission and immediate surgical/structural Heart Team assessment; stabilisation must not delay definitive intervention.

Purpose and principles

Match lesion, timing, anatomy and patient goals to the safest durable valve intervention through a Heart Team.

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.

Indications, selection and cautions

Symptomatic severe stenosisRed flag

Exertional breathlessness, angina, presyncope/syncope or heart failure with severe valve obstruction warrants prompt intervention review.

Ventricular trigger

Falling LVEF, progressive chamber enlargement, pulmonary hypertension or new AF may justify intervention before advanced symptoms.

Acute regurgitationRed flag

Pulmonary oedema or shock after papillary-muscle/chordal rupture, endocarditis or aortic dissection needs emergency surgical/structural assessment.

High-risk anatomy

Bicuspid valve, low coronary heights, small/large annulus, heavy LVOT calcification, aortic aneurysm or unsuitable access can redirect TAVI to surgery.

Potential futility

Severe frailty, irreversible organ failure, advanced dementia or symptoms dominated by non-cardiac disease require explicit benefit assessment, not automatic intervention.

Prosthetic failure

Degenerated surgical or transcatheter bioprostheses may be suitable for valve-in-valve treatment, but coronary obstruction and residual-gradient risk must be modelled.

Assessment before treatment

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 05
    Frailty, cognition and functional assessment
    Why
    Estimate recovery, independence and likely patient-valued benefit.

Treatment approach

01ASSevere aortic stenosisFirst stepSymptoms or another guideline trigger for valve replacement after severity is confirmed.+
  1. 1Exclude a reversible high-flow or measurement explanation and document symptom/ventricular trigger.
  2. 2AlternativeIf surgery is unsuitable and transfemoral anatomy is suitable, offer TAVI; if TAVI is technically unsuitable, discuss alternative access versus palliation.
  3. 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.
  4. 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.+

Regimens, contraindications and interactions

Single antiplatelet strategy after TAVI in NICE guidance.

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.

Complications, monitoring and follow-up

  • 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.

Special situations

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.

Common pitfalls

  1. 01

    Choosing TAVI or surgery from age alone before confirming an intervention indication and anatomy.

  2. 02

    Referring secondary MR for TEER before optimising HFrEF therapy and CRT eligibility.

  3. 03

    Assuming all severe primary MR is repairable outside an expert repair service.

  4. 04

    Ignoring post-TAVI conduction disease or coronary-access implications in a younger person.

  5. 05

    Failing to establish a post-procedure baseline echo and antithrombotic stop dates.

Practice

Two practice questions

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Question 1 of 2
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CardiologyOriginal SBA

TAVI or SAVR

An active 82-year-old has symptomatic severe calcific aortic stenosis, suitable transfemoral anatomy, no aortopathy or complex coronary disease, and acceptable expected survival. Both TAVI and SAVR are technically possible. Which strategy does NICE generally favour?

Choose one answer, then submit
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG208: Heart valve disease presenting in adultsUK TAVI/SAVR and mitral intervention choices.
  • 2025 ESC/EACTS valvular heart disease guidelineCurrent Heart Team, imaging and transcatheter/surgical framework.
  • NICE HTG518: Transcatheter aortic valve implantationUK procedural governance for TAVI.
  • NICE IPG731: Transcatheter tricuspid leaflet repairUK evidence/governance for tricuspid intervention.
  • NHS: Heart valve diseaseUK patient-facing recognition and treatment context.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
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.
    1. 1Have an expert repair team define mechanism and probability of durable repair.
    2. 2If surgical risk is acceptable and durable repair is likely, choose surgical repair rather than replacement.
    3. 3If surgery is unsuitable and the person remains symptomatic with suitable anatomy, consider mitral TEER after Heart Team review.
    4. 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.+
    1. 1Optimise evidence-based HF medicines, volume status, rhythm and CRT eligibility before labelling MR refractory.
    2. 2If CABG or another cardiac operation is indicated, assess concomitant mitral surgery.
    3. 3If no surgical indication and anatomy/ventricular profile predicts benefit, consider TEER in a specialist multidisciplinary service.
    4. 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.+
    1. 1Before discharge, document procedural result, rhythm/conduction status, access/wound complications and antithrombotic regimen.
    2. 2Create a baseline TTE for future comparison and arrange valve-clinic review.
    3. 3Explain dental hygiene, infective-endocarditis symptoms, medicines, rehabilitation and when new dyspnoea/syncope/fever needs urgent review.
    4. 4EscalationEscalate an early rising gradient, new regurgitation, haemolysis, conduction change or heart failure for prosthetic/repair imaging rather than waiting for routine follow-up.