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A narrowed aortic valve can now be replaced without opening the chest. A new valve is folded into a catheter, passed up an artery in the groin, and expanded inside the old one. Most people go home within a couple of days. Because the hospital stay is so short, nearly all the recovery and rehabilitation happens at home — which is where physiotherapy matters most.
What the procedure is
Transcatheter aortic valve implantation (TAVI, also called transcatheter aortic valve replacement or TAVR) treats severe aortic stenosis by delivering a bioprosthetic valve mounted on a stent frame through a catheter and expanding it within the diseased native valve. The old valve is not removed — it is pushed aside and becomes the anchor for the new one.
Transfemoral access is used in the great majority of cases and is done under local anaesthetic and sedation in many centres. Alternative routes — subclavian, transaxillary, transcaval and transapical — are used when the femoral vessels are unsuitable. The access route is the first detail to establish, because a transapical approach involves a small left thoracotomy and behaves like chest surgery, while a transfemoral case does not.
See Aortic Stenosis for the underlying condition and the thresholds for intervention.
Who receives it now
The indication has widened dramatically. TAVI began as a treatment for patients considered inoperable, then extended to high-risk and intermediate-risk patients,1 and following PARTNER 3 and the Evolut Low Risk trial it is now an established option in low surgical risk as well.2,3
Contemporary European guidance frames the decision around age, anatomy and life expectancy rather than a surgical risk score alone — broadly favouring TAVI in older patients with suitable femoral access, and surgery in younger patients where prosthesis durability over decades matters more.4 The decision is made by a multidisciplinary heart team.
Compared with surgical valve replacement
| TAVI | Surgical replacement | |
|---|---|---|
| Access | Catheter, usually femoral | Median sternotomy (or mini-thoracotomy) |
| Sternal precautions | None (transfemoral) | Yes — see Sternal Precautions |
| Length of stay | Commonly one to three days | Around five to seven days |
| Atrial fibrillation | Less common | Common |
| New permanent pacemaker | Substantially more common5 | Less common |
| Paravalvular leak | More common | Uncommon |
| Vascular access complications | Groin haematoma, pseudoaneurysm, limb ischaemia | Not applicable |
| Typical population | Older, frailer, more comorbid | Younger, fitter |
Complications that change the session
- Conduction disturbance and new pacemaker requirement. The expanded valve frame presses on the conduction system immediately below the aortic annulus, producing new left bundle branch block or complete heart block. A significant minority of patients leave with a permanent pacemaker.5 New dizziness or syncope during mobilisation warrants an electrocardiogram, not reassurance. See Pacemakers & Implantable Cardioverter Defibrillators.
- Vascular access site. Check the groin before mobilising. Expanding haematoma, a pulsatile mass, new limb pain or a cold foot are surgical problems. Local protocols usually specify a period of bed rest and limited hip flexion after sheath removal — follow them.
- Stroke. A recognised peri-procedural risk; new focal neurology requires immediate escalation.
- Acute kidney injury from contrast, which interacts with fluid balance and exercise tolerance.
- Bleeding on dual antiplatelet or anticoagulant therapy, relevant to fall risk in an older population.
Frailty is the outcome variable
This is an older, frequently frail population, and frailty predicts mortality and functional decline after aortic valve replacement more powerfully than most conventional risk markers. The FRAILTY-AVR study evaluated multiple frailty instruments in patients undergoing surgical and transcatheter valve replacement and found frailty to be strongly and independently predictive of poor outcome.6
Practical implication: gait speed, the Short Physical Performance Battery, grip strength and a simple sit-to-stand are all more informative here than a symptom score, and they are physiotherapy measurements. They belong in the pre-procedure assessment, not only in research.
Rehabilitation — the gap in the pathway
Because patients go home in one to three days, there is almost no inpatient rehabilitation window. The entire functional recovery happens after discharge, in a population that is old, deconditioned and frequently living alone. Referral rates into cardiac rehabilitation after TAVI are consistently lower than after surgery, despite the population having more to gain.
Systematic review and meta-analysis of cardiac rehabilitation after transcatheter compared with surgical aortic valve replacement found meaningful improvement in functional capacity in both groups, supporting rehabilitation after TAVI rather than treating it as a procedure that needs none.7
What to prescribe
- Mobilise early — usually the same or next day once the access site is stable and the protocol allows.
- No sternal precautions after transfemoral access. Patients and families frequently assume there are, and unnecessary caution costs function. Say so explicitly.
- Groin care for the first days: avoid straining, deep squatting and heavy lifting per local protocol.
- Progressive aerobic and resistance training, prescribed by perceived exertion. Many are on beta blockade or have a paced rhythm, so heart-rate targets are unreliable.
- Balance and falls prevention, which in this cohort is often the highest-value component and is frequently omitted from a cardiac programme.
- Refer, and check the referral was taken up.
After transapical access, treat the patient as having had thoracic surgery: analgesia, shoulder and thoracic mobility, and respiratory assessment. See Thoracic Surgical Approaches.
Role of the physiotherapist
Establish the access route first, because it determines whether this is chest surgery or not. Measure frailty and function rather than assuming them. Mobilise early and correct the mistaken belief that a valve procedure requires arm or chest restrictions. Prescribe by perceived exertion. Watch for conduction disturbance during exertion. And treat the cardiac rehabilitation referral as the main intervention, because for this group it is.
Evidence summary
Framing. TAVI has moved from a last resort to a first-line option across most of the age spectrum in under two decades, and the physiotherapy pathway has not kept pace.1,2,3,4 The defining features for rehabilitation are a very short inpatient stay, an older and frailer population than surgical cohorts, and a complication profile dominated by conduction disturbance and vascular access rather than by sternal healing or pulmonary complications.
Evidence — indication creepPARTNER 2 established non-inferiority in intermediate-risk patients; PARTNER 3 and Evolut Low Risk extended this to low surgical risk, with lower rates of stroke, bleeding and new atrial fibrillation but higher rates of permanent pacemaker implantation and paravalvular regurgitation.1,2,3 ESC/EACTS guidance now frames selection around age, anatomy and expected longevity.4
Evidence — frailty and rehabilitationFRAILTY-AVR demonstrated the independent prognostic weight of frailty in this population across several instruments.6 Meta-analysis supports cardiac rehabilitation after transcatheter valve replacement, with functional gains comparable to those after surgery.7 Conduction disturbance after implantation is common and well characterised.5
Physiotherapy implicationsAssess frailty objectively and pre-procedurally where the pathway allows. Do not import sternal precautions into a transfemoral pathway. Prescribe by perceived exertion given pacing and beta blockade. Build balance and falls work into the programme rather than treating it as a purely cardiac prescription. Treat referral uptake, not referral generation, as the outcome.
Evidence gapsThere is no adequately powered randomised trial of a rehabilitation model designed specifically for the transcatheter population, and most evidence is extrapolated from surgical cohorts. The optimal timing and setting — home, telehealth or centre-based — for a frail, rapidly discharged group is unresolved. Whether pre-procedural prehabilitation modifies outcome in frail candidates is being studied but not yet established.
References & evidence base
- Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients (PARTNER 2). N Engl J Med 2016;374(17):1609–1620.
- Mack MJ, Leon MB, Thourani VH, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients (PARTNER 3). N Engl J Med 2019;380(18):1695–1705.
- Popma JJ, Deeb GM, Yakubov SJ, et al. Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients (Evolut Low Risk). N Engl J Med 2019;380(18):1706–1715.
- Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2022;43(7):561–632.
- Auffret V, Puri R, Urena M, et al. Conduction disturbances after transcatheter aortic valve replacement: current status and future perspectives. Circulation 2017;136(11):1049–1069.
- Afilalo J, Lauck S, Kim DH, et al. Frailty in older adults undergoing aortic valve replacement: the FRAILTY-AVR study. J Am Coll Cardiol 2017;70(6):689–700.
- Ribeiro GS, Melo RD, Deresz LF, Dal Lago P, Pontes MR, Karsten M. Cardiac rehabilitation programme after transcatheter aortic valve implantation versus surgical aortic valve replacement: systematic review and meta-analysis. Eur J Prev Cardiol 2017;24(7):688–697.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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