Severe aortic stenosis: symptoms, assessment and TAVI or valve replacement

The aortic valve sits on the left side of the heart and opens and closes as blood is pumped from the main pumping chamber into the aorta. The UHS NHS website explains that in aortic stenosis the valve becomes narrowed and stiff because of calcium build-up, and the left ventricle has to work harder, gradually enlarging and becoming less efficient, leading to signs of heart failure. Guy's and St Thomas' says the extra force strains the heart and can cause fluid on the lungs, swollen ankles and eventually heart muscle weakness, and that if untreated it usually gets worse over time.

South Tees adds that the valve may sometimes have been abnormal from birth, or damaged by conditions such as rheumatic fever.

The trusts list breathlessness, chest pain or discomfort, dizziness when exercising, which can cause fainting, collapse or blackouts, and swollen ankles. Gradual breathlessness and reduced stamina are easily put down to age or being less active, and an older person may simply do less to avoid symptoms. Blackouts or chest pain on exertion deserve prompt medical assessment. If someone collapses or has chest pain that does not settle, call 999, as with any suspected heart emergency.

South Tees notes that as the narrowing worsens, the heart muscle weakens, which it describes as heart failure and which may become life-threatening over time. If the valve is not severely narrowed, no specific treatment is needed and routine check-up appointments monitor for deterioration.

South Tees lists routine tests as blood tests, an ECG, an echocardiogram and a detailed CT scan of the heart and main blood vessels, with some people also needing a transoesophageal echo, lung function tests or an angiogram to check the coronary arteries. Guy's and St Thomas' says tests check whether a TAVI is the best treatment, and that not everyone can have one because the heart and blood vessels must be suitable.

South Tees explains that every patient is discussed at a multidisciplinary meeting, with cardiologists, cardiac surgeons, specialist nurses, older people's medicine doctors and sometimes a cardiac anaesthetist, who recommend a plan. Where both surgery and TAVI are suitable, you may meet both teams. Frailty, other illnesses and your own wishes matter in this decision; Guy's and St Thomas' notes it is your decision whether to go ahead and you can change your mind at any time.

The three main routes described by South Tees are TAVI, open heart surgery and medicines alone. Guy's and St Thomas' also describes balloon aortic valvuloplasty, which stretches the valve and can help symptoms for 3 to 6 months before the valve narrows again, and does not improve life expectancy.

Guy's and St Thomas' lists risks including heart rhythm problems in 1 or 2 in 10 people, a slow heart rate needing a permanent pacemaker in 5 to 10 in 100, damage to an artery and a moderate to severe leaking valve in about 5 in 100 each, stroke and kidney injury in about 3 in 100 each, and heart attack or need for open surgery in fewer than 1 in 100, with rare risk of death. South Tees also lists confusion or disorientation after TAVI as an occasional effect that usually settles in a day or so but rarely lasts longer, which is relevant to older adults and families who should be warned about delirium risk.

Benefits quoted by the trusts include relief of the narrowed valve, improved heart function, improvement in chest pain, breathlessness and blackouts, and possibly improved quality of life and life expectancy. These figures are from individual trusts and the team will quote figures for your own circumstances; ask for them in writing.

South Tees says most TAVI patients are discharged the day after the procedure, sometimes the same day, and may need extra support in the short term; a referral to cardiac rehabilitation helps return to normal activities, and an echo is arranged around 6 weeks afterwards. Guy's and St Thomas' says an outpatient appointment follows, usually within 4 months. South Tees says the DVLA advises not driving for 4 weeks after the procedure and that you need not inform the DVLA but should tell your insurer; commercial licence holders must inform the DVLA.