Valvular Heart Disease and Structural Heart Intervention
Core concepts
Understand indications for TAVR vs. SAVR by surgical risk (STS score), anatomy (bicuspid, annulus size), and age. Know TAVR complications: paravalvular leak, conduction disturbance requiring pacemaker, coronary obstruction, stroke, and vascular injury. Master mitral interventions: MitraClip/TEER for primary (degenerative) and secondary (functional) mitral regurgitation in appropriate candidates, and the distinction between TEER and surgery. Know balloon aortic valvuloplasty as a bridge, not definitive therapy. Understand ASD/PFO closure indications (cryptogenic stroke with PFO, significant shunt) and left atrial appendage occlusion for stroke prevention when anticoagulation is contraindicated.
Traps
- Choosing TAVR in a low-risk young patient who should have SAVR.
- Missing that bicuspid valves and heavy annular calcification raise TAVR risk.
- Confusing primary vs. secondary MR indications for TEER.
- Forgetting that new left bundle branch block after TAVR may need pacing.
- Overlooking that LAA occlusion is for anticoagulation contraindication, not as first-line therapy.
Rule of thumb
Match therapy to risk and anatomy: TAVR for high/intermediate surgical risk or hostile anatomy; SAVR for low-risk younger patients. For MR, TEER is best supported in primary MR with prohibitive surgical risk and in selected secondary MR.
Worked example
An 84-year-old with severe aortic stenosis, STS score 8%, and suitable anatomy is offered TAVR. A 55-year-old with the same stenosis and STS 1% should have SAVR.