Synopsis
Match lesion, timing, anatomy and patient goals to the safest durable valve intervention through a Heart Team.
- 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.
Key red flags
Exertional breathlessness, angina, presyncope/syncope or heart failure with severe valve obstruction warrants prompt intervention review.
Investigation priorities
Confirm mechanism/severity and ventricular, pulmonary-pressure and multivalve consequences.
Management branches
Symptoms or another guideline trigger for valve replacement after severity is confirmed.
- Exclude a reversible high-flow or measurement explanation and document symptom/ventricular trigger.
- If surgery is unsuitable and transfemoral anatomy is suitable, offer TAVI; if TAVI is technically unsuitable, discuss alternative access versus palliation.
Key medicines
Aspirin after TAVI75 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.