Transcatheter Valve Interventions
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Direct answer
Transcatheter valve interventions replace or repair a diseased heart valve through a catheter, avoiding open-heart surgery. Transcatheter aortic valve implantation places a bioprosthesis inside the diseased aortic valve for severe symptomatic aortic stenosis, most often by the transfemoral route. MitraClip clips the mitral leaflets together in selected severe mitral regurgitation. A heart team weighs age, comorbidity, frailty and anatomy before choosing catheter or surgery.
What you must remember
- Severe aortic stenosis: valve area of 1 square centimetre or less, mean gradient of 40 mmHg or more and peak jet velocity of 4 metres per second or more.
- TAVI population: older patients or those with high or prohibitive surgical risk, judged by a heart team that scores frailty and comorbidity.
- Surgical preference: surgical aortic valve replacement remains the default in younger, low-risk patients, where long-term durability data are most established.
- TAVI complications: stroke, vascular injury, paravalvular leak and atrioventricular conduction block needing a permanent pacemaker; pre-existing right bundle branch block raises that risk.
- Balloon mitral valvotomy: for symptomatic rheumatic mitral stenosis with pliable leaflets, no left atrial thrombus and no more than mild mitral regurgitation.
- MitraClip: transcatheter edge-to-edge repair for suitable severe symptomatic mitral regurgitation when surgery is high risk, reducing the regurgitant orifice.
- Mechanical versus bioprosthetic valves: a mechanical prosthesis needs lifelong vitamin K antagonist therapy, whereas most bioprostheses do not.
Choosing between catheter and surgery
A 78-year-old woman with exertional syncope and an aortic valve area of 0.8 square centimetres has frailty and comorbidity that raise her surgical risk. The heart team compares the options against a fixed set of features.
| Feature | TAVI | Surgical AVR |
|---|---|---|
| Approach | Catheter, usually transfemoral | Sternotomy with cardiopulmonary bypass |
| Typical patient | Older or high surgical risk | Younger, low to moderate risk |
| Recovery | Usually shorter stay | Longer recovery over weeks |
| Durability evidence | Shorter follow-up, still accumulating | Longest experience |
| Pacemaker risk | Higher, from conduction injury | Lower, but present |
| Antithrombotic plan | Protocol-based antiplatelet or anticoagulant | Lifelong warfarin if mechanical |
Age alone does not decide the route, because frailty, life expectancy and valve anatomy carry more weight. Annulus size and coronary heights can shift the decision, so the table is a starting point rather than a rule. Expected life span and the likelihood of needing another valve procedure later both weigh in. Pre-procedure ECG review for conduction disease is therefore part of the decision, not an afterthought.
Where the exam tries to catch you
Valve questions often hinge on one anatomical or clinical detail.
- Trap: choosing TAVI on age alone Correct: frailty, life expectancy, annulus size and coronary heights decide, and the heart team confirms the choice.
- Trap: offering balloon valvotomy to every mitral stenosis Correct: heavy calcification, left atrial thrombus or significant regurgitation exclude it and point towards replacement.
- Trap: treating MitraClip as a substitute for surgery in all mitral regurgitation Correct: it suits selected severe symptomatic disease with suitable leaflets and high surgical risk, while operable primary regurgitation is still referred for surgery.
Frequently asked questions
What is the main indication for TAVI?
TAVI is indicated for symptomatic severe aortic stenosis in patients judged to be at high or prohibitive surgical risk. It is also chosen for older patients whom a heart team considers suitable, provided the anatomy fits the device.
Which valve lesion is treated with balloon mitral valvotomy?
Balloon mitral valvotomy treats symptomatic rheumatic mitral stenosis with pliable leaflets and no left atrial thrombus. Moderate or severe mitral regurgitation and heavy valve calcification are contraindications.
Which complication after TAVI most often needs a permanent pacemaker?
New atrioventricular conduction block most often needs a permanent pacemaker after TAVI. Pre-existing right bundle branch block increases this risk, which is why post-procedure ECG monitoring is standard.
When is MitraClip preferred over surgery for mitral regurgitation?
MitraClip is preferred when severe symptomatic mitral regurgitation has suitable leaflet anatomy and surgery is judged high risk. Surgical mitral repair remains the default for operable primary mitral regurgitation.