Aortic Stenosis:
Symptoms, TAVI or Surgery & When Action Is Needed

1. What is aortic stenosis?

The aortic valve is the valve between the left ventricle of the heart and the main artery (aorta). With every heartbeat it opens and lets blood out into the body. In aortic stenosis this opening is narrowed, usually because the valve leaflets have thickened and calcified over the years. The heart then has to pump against ever greater resistance.^¹,²

At first the heart muscle compensates by becoming thicker. This often works well for years and causes no symptoms. At some point the adaptation is no longer enough: breathlessness, chest tightness or dizziness develop, and later heart failure. Aortic stenosis is the most common heart valve disease treated by catheter or surgery in Europe; it becomes markedly more common with increasing age.^²

2. Severity and types

The narrowing is measured with a heart ultrasound (echocardiography). What counts is the speed at which blood shoots through the valve, the pressure difference in front of and behind the valve and the remaining opening area.^²

There are also special forms: in low-flow, low-gradient stenosis the heart pumps so little blood that the measurements look harmless despite a narrow valve. A stress echo with medication or a CT measurement of the valve calcium can then help. A distinction is also made by the shape of the valve: normal with three leaflets (tricuspid) or congenital with two leaflets (bicuspid) — this influences the choice of treatment.^²

3. Symptoms: breathlessness, chest tightness, dizziness

The three classic warning signs typically appear on exertion, for example when climbing stairs, walking uphill or carrying things:^¹,³

• Breathlessness and declining fitness — often so gradual that people unconsciously do less.
• Chest tightness (angina pectoris) — pressure or tightness behind the breastbone, because the thickened heart muscle needs more oxygen. Similar chest pain also occurs with coronary heart disease, which is often present at the same time.
• Dizziness or fainting on exertion — the heart cannot increase its output, and blood pressure drops.
• Late signs — breathlessness when lying down, a cough at night, water retention in the legs as a sign of heart failure, heart rhythm disorders such as atrial fibrillation.

One special feature is Heyde syndrome: in some people with severe stenosis, small malformed blood vessels in the bowel bleed, because the strong blood flow through the narrow valve destroys a clotting factor. The result is anaemia and black stool — particularly relevant if you take blood thinners. It often improves after valve replacement.^²

4. Causes and risk factors

• Age-related calcification — the most common cause. The process resembles hardening of the arteries and begins with small areas of inflammation and calcium deposits on the valve leaflets.
• Congenital two-leaflet valve — it wears out faster; people with it often need a valve replacement between the ages of 50 and 70. Not infrequently the main artery is also widened.
• Rheumatic fever — after untreated streptococcal infections in childhood; rare in Germany today.
• Contributing factors — high blood pressure, raised LDL cholesterol and lipoprotein(a), smoking, diabetes and chronic kidney disease.

5. Diagnosis: heart murmur, echo and heart team

Aortic stenosis is often first noticed when a doctor listens to the heart: as a harsh murmur during the heartbeat that radiates up into the neck arteries. A step-by-step assessment follows:^²

• Heart ultrasound (echocardiography): the central examination. It shows the severity, pumping function and thickness of the heart wall; occasionally supplemented by an ultrasound via the oesophagus.
• ECG and blood tests: for example the heart hormone NT-proBNP as a sign of strain on the heart, plus kidney values and blood count.
• Exercise test: only in people without symptoms — it can uncover hidden symptoms. If symptoms are already present and the stenosis is severe, it is dangerous and is not done.
• Computed tomography: measures the valve calcium when findings are unclear, and before a TAVI it is used to plan the valve size and the access route via the blood vessels in the groin.
• Cardiac catheterisation or CT of the coronary arteries: before the procedure, to detect narrowed coronary arteries that can be treated at the same time.

The decision on the procedure is made by a heart team of cardiologists and cardiac surgeons. In Germany, the directive of the Federal Joint Committee (G-BA, the body that sets the rules for statutory health insurance) stipulates that catheter valves may only be implanted in hospitals that have both specialist departments.^⁴ Bring an up-to-date medication plan to the consultation, especially regarding blood thinners; the guide Preparing for a doctor’s appointment offers tips.

6. Treatment: when action is needed

A narrowed valve cannot be widened with tablets. The only effective treatment is valve replacement. The crucial question is therefore the right timing. The 2025 European guideline names the following situations:^²

People who are very old or have serious other illnesses do not always benefit from a procedure. This too belongs honestly in the conversation: the goal is not valve replacement at any price, but a gain in quality of life. The decision lies with the heart team together with you and your family.^²

7. TAVI or surgery?

There are two routes to valve replacement. Which one is suitable depends above all on age, valve shape, blood vessels and other illnesses.^²,⁴

With surgery there is also the choice between a mechanical valve and a biological valve. Mechanical valves hardly wear out, but require a vitamin K antagonist such as phenprocoumon for life. Biological valves usually do not need permanent anticoagulation, but wear out over the years; a worn biological valve can then often be replaced with a new one by catheter (“valve-in-valve”). Younger people are therefore more likely to be recommended a mechanical valve and older people a biological one — with individual leeway in between.^²

To put it honestly: TAVI has greatly changed the treatment of older people because it is gentler. In younger patients, however, there are still no robust data on how long catheter valves last. Balloon stretching of the valve on its own only works for a short time and is therefore used at most as a bridge.

8. Medicines: what they can and cannot do

No medicine slows the progression of aortic stenosis. Medicines treat accompanying illnesses and relieve symptoms until the valve is replaced. The rule here: a heart pumping against a narrow valve reacts sensitively to blood pressure that is too low and to too little fluid.^²,⁵

Diarrhoea, vomiting, fever or heat can also lower blood pressure through fluid loss. If you take water tablets, discuss with your practice on such days whether the dose should be adjusted; see Medications and heat. Which medicines you take, and at what dose, is always decided by the treating practice.

9. After valve replacement: blood thinners and endocarditis protection

Which anticoagulation you need afterwards depends on the type of valve and on other illnesses. Simplified, the guideline says:^²,⁵

• After TAVI with no other reason for blood thinning: an antiplatelet medicine for life, usually low-dose aspirin or alternatively clopidogrel. Dual antiplatelet therapy is now only used in special cases, for example after a recent stent.
• After TAVI with atrial fibrillation: as a rule only the anticoagulant, without additional aspirin, because the combination increases the risk of bleeding.
• After a surgical biological valve: aspirin or an anticoagulant in the first few months, then depending on other illnesses.
• Mechanical valve: a vitamin K antagonist for life with regular INR checks; the target range depends on the type of valve and risk factors. Direct oral anticoagulants (DOACs) are not suitable here and some are explicitly contraindicated.

Endocarditis protection: with any artificial heart valve — including after TAVI — there is an increased risk of a bacterial infection of the inner lining of the heart (endocarditis). Before dental treatment that injures the gums, the guideline therefore recommends a preventive antibiotic, usually a single dose of amoxicillin shortly before the procedure; if you have a penicillin allergy, there are alternatives. At least as important are good oral hygiene and dental check-ups once or twice a year. An endocarditis card, for example from the German Heart Foundation (Deutsche Herzstiftung), quickly informs dental practices.^⁶ Before other procedures: only pause blood thinners after discussing it first; see Medications before surgery.

10. Everyday life with aortic stenosis

• Take symptoms seriously — if you notice that you avoid stairs or stop more often, that is important information for your next check-up, not normal ageing.
• Exercise yes, feats of strength no — light to moderate exercise is encouraged with mild and moderate stenosis. With severe stenosis you should avoid heavy lifting, straining and competitive sport, and discuss your limits with your practice; see Medications and exercise.
• Keep an eye on your blood pressure — both values that are too high and values that are too low are unfavourable. Measuring regularly and noting the values with the time helps your practice with the adjustment.
• Look after your teeth — good oral hygiene lowers the risk of endocarditis, especially after valve replacement.
• Get active after the procedure — after surgery, cardiac rehabilitation is usual; after TAVI, many people are quickly back on their feet. Regular echo check-ups of the new valve remain part of follow-up care.

Many people with aortic stenosis also take medicines for high blood pressure, raised blood lipids, diabetes or atrial fibrillation. After valve replacement, anticoagulants are added. An up-to-date medication plan that your GP practice, cardiology practice and dental practice all know about prevents dangerous duplications and gaps.

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