Aortic stenosis and TAVI for GPs: Heyde syndrome, when “asymptomatic” severe AS needs a valve, and valve-in-valve

Speaker

Interventional cardiologist performing TAVI — identified by role only. Otter labels the speaker “Speaker 1” / “Unknown Speaker”; no name is spoken. He describes doing TAVI for ~10 years, catheter-directed treatment of a massive PE, coronary angiography and valve work in the first person.

Audience

GPs ask about valve longevity, repeat TAVI, post-procedure antiplatelets, dental prophylaxis, procedure time and cost (unnamed). No sponsor or disclosure statement was captured.

Session context

Otter title Aortic Stenosis Treatment Overview · id Tcfxh33ckbowzDkUUpq4wc523_c · ~22 min, recorded 21 March 2026 1:07 pm AEST (same CPD day as the PE, anorectal and gynaecology talks). Valve samples were passed around the room (“don’t open that one — it’s in formaldehyde”). The session ends with lunch being called.

Key messages for GPs

• Listen to the chest. The 67-year-old in Case 1 had a loud aortic-stenosis murmur that, by his account, no one had picked up.
• Severe AS can present acutely — chest pain, breathlessness, chest heaviness or syncope — which is why the speaker calls it a “lights and sirens” condition.
• Unexplained iron-deficiency anaemia or GI bleeding + an AS murmur → think Heyde syndrome (aortic stenosis with bleeding from GI angiodysplasia). Fixing the valve is expected to settle the bleeding.
• Once severe AS is symptomatic, about 50% die within two years (as stated) — “it’s like cancer”. Tease out symptoms, because patients quietly slow down.
• Echo thresholds as spoken: mean gradient >40 mmHg marks severe; moderate or moderate-plus AS needs a yearly echo, and ideally a cardiologist keeping an eye on it.
• Tissue valves (surgical or TAVI) last about 10–12 years; failed tissue valves can often be treated with valve-in-valve TAVI. Mechanical valves cannot.
• After TAVI: if the patient was on nothing, aspirin only; otherwise continue their existing clopidogrel, NOAC or warfarin. Dental prophylaxis is the same as for any prosthetic valve.

Warm-up: a massive PE in the cath lab

Before his main talk the speaker showed a case the room had already heard about. A patient with a massive pulmonary embolism was “dying”. He passed a catheter into the main pulmonary artery, where contrast showed almost no flow. Thrombolysis through the catheter didn’t work. He then broke up the clot by hand (mechanical disruption), which restored enough flow to get the patient off the table. The patient later had formal clot extraction with dedicated catheters that weren’t in that lab on the day. He is alive and back at work. The speaker said he had never done this before (“nothing for me to lose”).

For the full talk on massive-PE options, see the companion page on pulmonary embolism treatment, recorded the same morning.

Why aortic stenosis is “lights and sirens”

The CPD theme was emergencies, and AS fits because some patients present acutely. Severe, haemodynamically significant or critical aortic stenosis can cause:

• chest pain or chest heaviness
• shortness of breath
• syncope

Case 1: Hb 44, black stools and a loud murmur — Heyde syndrome

This case came from the week of the talk:

• 67-year-old man through ED with exertional chest tightness, breathlessness, tiredness and lethargy; background hypertension, hyperlipidaemia and diabetes.
• Examination in ED found “not much”; ECG normal; troponin 60 (described as highly elevated); haemoglobin 44 — one of the lowest the speaker had seen.
• Anaemia alone would explain the breathlessness, the chest tightness and a type 2 (supply–demand) troponin rise, so admission under cardiology was a fair call.
• On history: known anaemia, investigated before with “nothing found”, and treated with iron infusions. He had had black stools for some time, though he also took a medication that can darken stools (the drug name is garbled in the transcript).
• On examination: a loud murmur. The patient said nobody had ever listened to his chest.
• Echo next day confirmed critical aortic stenosis. Over three days he received seven units of blood; Hb reached only 91.
• Coronary angiography showed coronaries that looked “pretty good” despite his risk factors, so no stent or bypass was needed. Only the valve needs fixing.

The unifying diagnosis was Heyde syndrome. The speaker spelled it out (“H-E-Y-D-E, look it up”) — Otter wrote “Hades”. It is aortic stenosis with GI bleeding from angiodysplasia. A GP in the room suggested haemolysis. The speaker said that was on the right track, but he would expect haemolysis with a mechanical valve, not a native one. His expectation: once the valve obstruction is fixed, the bleeding settles. Gastroscopy and colonoscopy will still be done, but he didn’t want them done at Hb 44 because the patient would be haemodynamically unstable. He suspects (and the gastroenterologist agrees) they will find nothing.

TAVI or surgical valve at 67?

With critical AS at 67, the question is which way to go. The speaker’s reasoning:

• Tissue valves don’t last forever — surgical tissue valves and TAVI valves alike last “about 10–12 years at most”. They then fail by stenosis or regurgitation (garbled in the transcript), and quite often fail acutely.
• Patient preference is part of the decision.
• Technically, a younger patient is an easy TAVI: less vessel tortuosity, less calcium.
• At 77 it would be straightforward — “just pop in the TAVI”. At 67 it is “not an easy one”. Asked which way he was leaning, he said he hadn’t decided (“see how I feel on the day”).
• Repeat TAVI is possible: when a TAVI valve fails after ~12 years, a valve-in-valve TAVI can be done. His team has done many valve-in-valve TAVIs inside failed surgical tissue valves and is starting to do them inside failed TAVI valves.
• The exception is a mechanical valve — valve-in-valve cannot be done inside one.

Case 2: a 32-year-old mechanical mitral valve

Also that week: a woman whose mechanical mitral valve is failing after 32 years (“very good” durability). She was on warfarin and came in under the haematologist with anaemia by a different mechanism. She has mechanical haemolysis with iron deficiency, an LDH around 1100 and a very low haptoglobin. Because valve-in-valve isn’t possible inside a mechanical valve, she needs a redo operation (“there’s no other choice”).

What a TAVI valve is, and how it is sized

• Two families: self-expanding and balloon-expandable valves. They look different and deploy differently, but do the same job.
• Leaflets: animal (pig or cow) pericardium — not the animal’s own valve — stitched into three leaflets by the manufacturer.
• Frame: metal, with a fabric skirt (PTFE as spoken) to prevent paravalvular leak.
• MRI: the speaker said patients can have MRI with these valves.
• Sizing: everyone’s aortic root is different. Work-up includes echo and a dedicated CT scan; CT sizes the valve better than echo and decides which valve and size goes in.

After TAVI: antithrombotics, dental cover, rehab

Severity, symptoms and when to refer

• Mean gradient >40 mmHg on echo is where moderate becomes severe. The speaker also mentioned a valve-area threshold (garbled; probably <1 cm²).
• Moderate / moderate-plus: echo every year. By then, ideally hand over to a cardiologist to keep an eye on the patient.
• Severe but truly asymptomatic (e.g. a patient over 80 with a mean gradient just over 40): he might hold off a little longer. With gradients of 50+ and no symptoms, he reviews every six months.
• Gradient 60–70: he would suggest going ahead.
• Watch for hidden symptoms. Many “asymptomatic” patients have simply slowed down and stopped pushing themselves.
• Symptomatic severe AS: ~50% mortality at two years (as stated) — “like cancer, so you should treat it”.

Mitral edge-to-edge repair: the speaker’s view

He was asked about transcatheter mitral work. Transcatheter edge-to-edge repair became available around the same time as TAVI. He chose not to take it up: in his view the results are “pretty average” and “you don’t get the same gratification”. The mitral space “still has a lot to go”. TAVI, by contrast, has had “very good results” over the ten years he has done it.

Cost and the uninsured patient

• The valve alone costs about $27,000. With everything else, the total is about $50,000 (as stated).
• About six months earlier, an uninsured woman in her 80s chose to pay for it herself (“just get it done”). His lesson: “you don’t know until you ask.”

GP clinic checklist

1. Auscultate any older patient with exertional chest symptoms, breathlessness, syncope or unexplained anaemia.
2. Recurrent iron-deficiency anaemia / occult GI bleeding with “nothing found” on scopes + systolic murmur → echo; consider Heyde syndrome.
3. Moderate AS → yearly echo and cardiology follow-up.
4. Severe AS: ask carefully about symptoms and reduced activity. Symptomatic patients have ~50% two-year mortality (as stated) → refer for intervention.
5. Anaemia with a mechanical valve → think haemolysis (LDH, haptoglobin).
6. After TAVI: aspirin if on nothing; otherwise continue existing antiplatelet / anticoagulant. Dental prophylaxis as for any prosthetic valve.
7. Tissue valves last ~10–12 years; valve-in-valve TAVI is often possible, but not inside mechanical valves.
8. Don’t assume an uninsured older patient can’t or won’t self-fund — ask.

Transcript caveats

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