Cardiac catheter or open-heart surgery? In the treatment of heart valve disease, catheter-based procedures are taking on an ever larger role, and the choice of the right method is one that matters for you personally. That choice depends on the risk of the procedure, the expected result and, increasingly, on your own wishes. At Dein Team Herzzentrum in Zürich, a heart team discusses every finding together before anything is decided.

What is heart valve disease and how is it treated?

Heart valve disease refers to a congenital or acquired malfunction of one of the four heart valves. These valves act as one-way gates: when they work correctly, they direct the flow of blood and prevent it from running back in the wrong direction. The valves most often affected are the aortic valve, frequently narrowed by calcification (aortic stenosis), and the mitral valve, frequently leaking (mitral regurgitation). Such valve disorders can go unnoticed for a long time, yet they may worsen, trigger heart failure and shorten life expectancy. Typical complaints are tiredness, shortness of breath, dizziness or brief loss of consciousness. Mild defects usually need only regular check-ups, and medication relieves the symptoms. With a relevant defect, timely repair or valve replacement is often needed to prevent lasting damage to the heart. The choice between open surgery and a catheter procedure is made by the heart team together with you.

Open surgery or a catheter-based method?

Choosing the right moment and the appropriate method is decisive for each individual. Both valve disorders can be operated on the open heart or, for around 15 years now, treated minimally invasively via a catheter, which is usually introduced through the femoral artery in the groin.

In the catheter procedure, the valve is repaired or replaced through this access route. The advantage is clear: the chest remains closed, and the heart does not have to be stopped. The procedure is therefore gentler, and the recovery time is usually shorter. This carries particular weight for older or frail patients. Often the catheter procedure is in fact the only option when the risk of surgery would be too high. Because of the good experience with it, it is now increasingly considered for people with moderately elevated risk as well.

The current ESC/EACTS guideline of 2021 recommends that the choice of method in severe aortic stenosis be made by a heart team. The team weighs age and life expectancy, the anatomy, the individual surgical risk, the feasibility of access via the groin and your own preference against one another [ESC/EACTS 2021, Eur Heart J].

Aortic stenosis and the TAVI procedure

One of the most common valve defects is narrowing of the outlet valve of the left heart, aortic stenosis. The valve usually calcifies over the course of life and then no longer opens fully. If symptoms occur in severe stenosis, the valve should be replaced. Today the heart team determines the severity with ultrasound, for instance a transoesophageal echocardiogram (TEE), or through a cardiac catheterisation.

Aortic stenosis is strongly age-dependent. Among people over 80, the prevalence is close to 10% [Osnabrugge 2013, JACC]. At this age, open surgery often carries too great a risk. Surgery does achieve very good results in valve replacement, but in high-risk patients the TAVI procedure (transcatheter aortic valve implantation) is now used in most cases.

In several countries, TAVI for aortic stenosis is now performed more often than open surgery. In Switzerland, the procedure has developed into a standard intervention since the first implantation in 2010 [Swiss Heart Foundation 2024]. Nevertheless, some points remain to be considered. The likelihood of needing a pacemaker after TAVI is higher than after surgery. In meta-analyses, the pacemaker rate after TAVI is around 11 to 12% [Sá 2024, systematic review]. A slight leak beside the valve (paravalvular leakage) also occurs somewhat more often after the catheter procedure than after surgery.

Which factors influence the outcome of treatment?

Roughly summarised, the heart team weighs these criteria:

  • the experience and close collaboration of the treating physicians
  • the selection of the appropriate catheter valve
  • whether the anatomical situation is suitable for a catheter intervention
  • the individual risks of open-heart surgery
  • the level of risk posed by the disease itself
  • age
  • whether the aortic stenosis is severe and causing symptoms

These points cannot be weighted in a blanket fashion. That is exactly why the heart team exists: it brings cardiology, cardiac surgery and imaging to one table and places your findings in the overall picture.

Mitral regurgitation and the MitraClip

Another common valve defect is leakage of the inlet valve of the left heart, mitral regurgitation. Here blood flows back from the left ventricle into the left atrium, from which it has just been pumped. This leads to complaints such as breathlessness and dizziness. Depending on the cause and age, the prevalence can be considerable.

The aim of treatment is to stop the backflow, relieve the symptoms and restore physical capacity. Classically this is done through surgery or drug therapy. For some years now, a catheter procedure has also been available. The most common of these is repair with a MitraClip, a small clip that joins the valve leaflets.

Every intervention is preceded by a thorough examination. The heart team defines the desired result and weighs the risk of open-heart surgery. In secondary (functional) mitral regurgitation with concurrent heart failure, the COAPT trial showed that catheter repair can reduce mortality and the number of hospital admissions for heart failure; this benefit persisted over five years [Stone 2023, NEJM].

Arguments in favour of MitraClip therapy:

  • with suitable anatomy, very good results can be achieved
  • even with less suitable anatomy, the leak is often reduced enough for the symptoms to improve markedly
  • the procedure is considered comparatively safe
  • the result can be checked during the procedure itself and corrected if necessary
  • hospital stay and recovery time are generally shorter

Frequently asked questions about treating heart valve disease

When does a heart valve defect actually need treatment? Many mild valve defects need only regular check-ups. Treatment generally becomes necessary when the defect is severe and causes symptoms, or when the first signs of incipient damage to the heart muscle appear. The heart team determines the right moment on the basis of ultrasound and exercise test findings.

Is the catheter procedure always better than surgery? No. Both procedures have their place. In younger people with low surgical risk, surgery may still be the better choice, for instance because surgically implanted valves show paravalvular leakage less often. In older patients or those with pre-existing conditions, the advantages of the gentler catheter procedure often prevail. The individual assessment is what counts.

How long does recovery take after TAVI? Because the chest remains closed, recovery is usually much shorter than after open surgery. Many patients are mobile again after a few days. The exact course depends on age, accompanying conditions and the individual findings.

Is a pacemaker needed after TAVI? Not in every case. The likelihood is higher than after surgery, though. In meta-analyses, around 11 to 12% of those treated need a pacemaker after TAVI [Sá 2024]. The risk depends among other things on the anatomy and the type of valve used, and it is discussed with you before the procedure.

What does secondary mitral regurgitation mean? In the secondary (functional) form, the valve itself is largely intact, but it no longer closes properly because the heart is enlarged or weakened. In this form with concurrent heart failure, catheter repair with the MitraClip can improve the prognosis [Stone 2023, NEJM].

Who decides which method is right for me? This decision is made by the heart team together with you. Cardiology, cardiac surgery and imaging pool their assessments, place the findings in context and discuss the options openly with you. Your own preference is expressly part of the choice; this is also what the current ESC/EACTS guideline recommends [ESC/EACTS 2021].

Does insurance in Switzerland cover such procedures? Valve procedures such as TAVI or MitraClip are part of the Swiss benefits catalogue, the list of services paid for by compulsory health insurance, when the indication is met. The outpatient components are billed via TARDOC, the Swiss tariff for outpatient medical services. What exactly is covered depends on the individual case and can be clarified before the procedure.