Surgical aortic valve replacement vs transcatheter aortic valve implantation: the role of both techniques in the treatment of severe aortic stenosis

Abstract

Aortic stenosis (AS) is the most common acquired valvular heart disease in adults worldwide, particularly affecting individuals over 75 years of age. It is characterized by rapidly progressive narrowing of the aortic valve, leading to left ventricular outflow tract obstruction that causes hypertrophy and, eventually, heart failure. Clinical symptoms, such as dyspnea, chest pain, and syncope, typically occur on exertion and indicate worsening of the disease. Without intervention, symptomatic AS carries a poor prognosis, with an average lifespan of 2 to 5 years. Pharmacological treatment is not effective, and the only feasible solutions are surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). While SAVR has been the traditional approach for decades, TAVI has emerged as a minimally invasive alternative, especially suitable for older patients and those at an increased surgical risk. Advances in valve technologies, including sutureless and long-lasting bioprosthetic models, have improved patient outcomes, deferring the need for a secondary intervention. Comparative trials (eg, PARTNER and NOTION) show similar long-term outcomes with respect to mortality and stroke rates, although each method has its risks and complications. In short, TAVI is associated with higher rates of pacemaker implantation and vascular complications, whereas SAVR carries the risks of bleeding, extended hospitalization, and prolonged recovery. Selection of the optimal treatment approach should be personalized, with involvement of a multidisciplinary heart team in the decision-making process. As the population ages, the prevalence of AS, as well as the demand for effective, individualized interventions, are expected to rise.

Introduction

Aortic stenosis (AS) is the most common acquired valvular heart disease in the adult population worldwide. It is characterized by progressive narrowing of the aortic orifice, causing obstruction of blood flow from the left ventricle to the aorta, and, consequently, increasing pressure load on the left ventricle. If the defect is not corrected, this leads to left ventricular hypertrophy and progressive heart failure (HF).¹ The accompanying clinical symptoms are not specific; they include dyspnea, chest pain, and syncope associated with exertion, which worsen with increasing severity of the valvular disease. Without corrective treatment, the average survival time from the onset of the first symptoms is 2 to 5 years.² Due to the increasing life expectancy of the population, the number of patients with significant AS is systematically rising, and this trend will likely continue in the coming years. It is currently assumed that up to 3%–4% of individuals over 75 years of age may be affected by this valvular pathology.³ Until recently, the gold standard of treatment, regardless of patient age, was surgical aortic valve replacement (SAVR); however, since the beginning of the 21st century, a less invasive method, transcatheter aortic valve implantation (TAVI; or transcatheter aortic valve replacement, which is the term used in the United States), has been gaining in importance.⁴ Since the first successful human procedure performed by Professor Alain Cribier in 2002, substantial research knowledge has been gained on this technology, leading to its significant development and rendering it a viable alternative to classic cardiac surgery, especially in higher-risk patients.

The aortic valve is located between the left ventricle and the aortic root that extends to the ascending aorta. Its main task is to allow blood to flow into the aorta during ventricular systole and prevent it from reversing during cardiac diastole. Stenosis typically progresses due to degeneration, thickening, and calcification of the valve leaflets, resulting in their stiffening and, consequently, limited mobility.⁵ The calcification process affects the entire valve apparatus, often including the aortic annulus.

In younger patients, the most common cause of left aortic outflow stenosis is congenital bicuspid valve, which is most often associated with fusion of the left and right coronary leaflets. Other causes include endocarditis, amyloidosis, or, less frequently, rheumatic fever.⁶

From a pathophysiological perspective, AS results in a significant elevation of intracavitary pressure within the left ventricle. Prolonged exposure to these conditions induces structural and functional adaptations within myocardial tissue, a process commonly referred to as cardiac remodeling.⁷ In this case, remodeling is characterized by the development of concentric hypertrophy of the left ventricular myocardium, an increase in rigidity and stiffness of the ventricular walls, and a concomitant reduction in myocardial compliance during diastole. Such morphological and functional alterations consequently impair the diastolic filling capacity of the ventricle, leading to increased myocardial oxygen demand and a decreased ability to accommodate normal coronary artery blood volume during relaxation phases. Over time, these changes predispose the myocardium to ischemic injury, resulting from an imbalance between decreased oxygen supply and increased oxygen demand. The ischemic environment can also promote electrical instability within the cardiac tissue, thereby elevating the risk of arrhythmogenic events.¹ Ultimately, these pathophysiological processes culminate in clinical manifestations indicative of HF, including dyspnea, fatigue, and fluid retention, which significantly impair the patient’s overall cardiovascular health and quality of life.

Preprocedural diagnostics

Transthoracic or transesophageal echocardiography is typically used to assess the severity of valvular disease and coexisting defects, such as mitral valve insufficiency, which may influence the decision regarding surgical correction. It is also a standard periprocedural imaging tool employed during both TAVI and SAVR procedures.

With respect to blood indicators, natriuretic peptide concentration can be used to predict survival in asymptomatic patients, and to assess prognosis in individuals with normal and low-flow severe AS.⁸

Coronary angiography is required before both TAVI and SAVR to determine the potential need for simultaneous coronary artery revascularization.

Computed tomography (CT) provides valuable information on the anatomy of the heart, bulb, and ascending aorta, as well as on the extent and location of calcifications in the valves and vessels. Additionally, it facilitates the assessment of vascular access, making it an essential element in TAVI planning.⁹

In some patients qualified for TAVI or SAVR, balloon aortic valvuloplasty can be used as a bridging therapy, particularly in the cases of decompensated AS, as well as in the individuals with severe AS who require urgent noncardiac surgical intervention due to a high surgical risk.¹⁰

Current therapeutic strategies

Surgical aortic valve replacement

SAVR is a classic and highly effective method of AS treatment. It involves surgical removal of pathologically altered leaflets and surrounding calcifications, and implantation of a new prosthesis. The procedure is performed under general anesthesia, and surgical access can be achieved through median sternotomy. The so-called minimally invasive access methods include ministernotomy, right lateral minithoracotomy, and the transaxillary access.

Selection of the appropriate method of access to the heart is primarily determined by anatomical conditions, surgical skills, and coexisting diseases (eg, status postradiotherapy, presence of adhesions, and other factors hindering maneuverability in the surgical field). Patient’s opinion and their consent are also very important factors in the decision-making process.¹¹ Two main types of prostheses are currently used in SAVR: mechanical and biological. Before surgery, a thorough interview with the patient is conducted to determine the most suitable prosthesis type. Mechanical prostheses are more durable but require lifelong oral anticoagulant (OAC) treatment, which is an important factor to consider before making a decision. Some mechanical valves are designed to work with lower international normalized ratio (INR), for example, the mechanical On-X valve (CryoLife Inc., Kennesaw, Georgia, United States), which requires an INR between 1.5 and 2. Mechanical heart valves are generally not recommended for patients with contraindications to anticoagulation or women planning pregnancy. Despite decades of experience, there are still cases of valve thrombosis once acenocoumarol or warfarin is replaced with a non–vitamin K antagonist oral anticoagulant, which might lead to severe valve damage and even death.¹² Biological prostheses (eg, made of bovine pericardium) do not require OAC therapy, but may degenerate over time.

In recent years, technologies used to produce biological heart valves have been widely improved. The modern biological models lately introduced to the market, such as Inspiris Resilia (Edwards Lifesciences LLC, Irvine, California, United States), are characterized by modified tissue preservation techniques, which ensure much better durability of the material.^13-15 A remarkable achievement in valvular cardiac surgery are the so-called sutureless valves, which allow for faster implantation and shorter surgery times. Examples of these valves include the Perceval Sutureless Aortic Valve (Sorin Group USA, Arvada, Colorado, United States), Medtronic 3f Enable Aortic Bioprosthesis (Medtronic, Inc., Minneapolis, Minnesota, United States), JenaValve Trilogy TAVR System (JenaValve Technology, Inc., Irvine, California, United States; CE-marked, investigational in the United States).^16,17 The lack of sutures and a large internal lumen, known as the effective orifice area, ensure a low pressure gradient through the valve and better laminar blood flow, which renders these prostheses similar to a natural human valve. These features help reduce the load generated on the left ventricle, improving the left ventricular function postoperatively. Cardiac valve replacement surgery is always performed in extracorporeal circulation, which may be associated with some perioperative risks. Recovery is prolonged, and the patient requires cardiac rehabilitation as well as monitoring of the postoperative wound healing. Nevertheless, despite its greater invasiveness, SAVR offers a long-term and comprehensive solution.

Transcatheter aortic valve implantation

TAVI is a minimally invasive procedure involving implantation of a new aortic valve using catheters, most often through the femoral artery approach.³ Other possible access points include the carotid artery, subclavian artery, and apex of the heart.¹⁸ Once the catheter reaches the aorta, the valve is placed inside the calcified, nonremovable native valve using a specially designed delivery system, and expanded, either with a balloon or spontaneously (self-expanding models).¹⁸ The key aspect of this procedure is the self-anchoring mechanism of the newly implanted TAVI valve, which prevents it from migrating. The clear benefit of TAVI is that it is usually performed under local anesthesia, with sedation only.¹⁸ TAVI was initially reserved for patients at a high surgical risk or those with contraindications to standard cardiac surgery.¹⁹ This recommendation has changed over time, and TAVI is currently increasingly used in patients at a medium or even lower risk, based on an individual assessment by a heart team.²⁰ The entire procedure takes only about 1–2 hours, depending mainly on the access conditions. TAVI is less invasive than SAVR, but this does not mean that it is entirely safe. Complications observed after the procedure include perivalvular leak, atrioventricular block requiring pacemaker implantation, and postprocedural renal dysfunction related to the use of a contrast agent.¹⁸

Several scales are used to assess patients referred for TAVI, such as the Clinical Frailty Scale or the Norton Scale. They help clinicians predict the procedural risk, assess frailty, and evaluate the process of recovery. In patients with degenerated bioprostheses, TAVI valves can be implanted inside the existing failed prosthesis. This procedure is called valve-in-valve TAVI.²¹

Short-term results

The PARTNER 1 (Placement of Aortic Transcatheter Valves) study²² was a crucial clinical trial, providing scientists with answers to questions about the new technology and offering doctors clear directions for the effective treatment of their patients. Later, this study formed one of the foundations for the European and American guidelines for the treatment of AS.

Briefly, it was a cohort study involving 3105 patients, of whom 348 were treated with TAVI and 351 underwent traditional SAVR.¹ The mortality rates observed at 1, 2, and 3 years were comparable between the 2 methods in a population characterized by a high surgical risk due to severe AS.² Furthermore, the study provided a comprehensive comparison of TAVI and SAVR over a 5-year period, based on data collected from a multicenter cohort enrolled at 25 medical centers located across Canada, Germany, and the United States.³

The PARTNER 2 study²³ aimed to evaluate the efficacy of TAVI in patients at an intermediate surgical risk. In summary, the study randomized 2032 patients (including only 94 cases with severe AS and cardiac symptoms) with intermediate-risk clinical profiles based on the Society of Thoracic Surgeons (STS) risk scale to receive TAVI or SAVR. The patients were enrolled at 57 centers.⁴ TAVI was associated with a lower overall mortality rate at 1 year, as well as lower rates of all-cause mortality and rehospitalization due to valve dysfunction at 1 year.⁵ Complications were more common in the SAVR group, including a 30% higher rate of major bleeding, a 2% higher rate of acute kidney injury, and a 16% higher rate of incident atrial fibrillation.¹¹ In contrast, TAVI was associated with a 3% increase in major vascular complications, including cerebrovascular events, such as transient ischemic attack and stroke.¹⁰

PARTNER 3²⁴ was a natural consequence of the 2 previous PARTNER studies. It showed that in patients with symptomatic, severe AS who were at a low surgical risk, TAVI was associated with a 6.6% absolute reduction in death, stroke, or rehospitalization at 1 year, as compared with SAVR. The superiority of TAVI was driven by symmetric reductions in each component of the primary end point, including a 1.5% absolute reduction in overall mortality.^8,20

Hypoattenuated leaflet thickening (HALT), or low-attenuation leaflet thickening, represents subclinical leaflet thrombosis visualized on CT. Although usually asymptomatic, it can also worsen, leading to reduced leaflet motion (hypoattenuation affecting motion) and potentially impacting valve function and clinical outcomes, such as stroke, transient ischemic attack, and other complications. The rate of HALT was reported to be higher with TAVI than with SAVR at 30 days, but not at 1 year.²⁵ HALT appeared to be a dynamic process that spontaneously resolved in more than 50% of patients by 1 year.²⁵ Valve hemodynamics were similar over 5 years (significant for a by 1 mm Hg decrease in favor of SAVR).²⁶

Other critical publications, such as meta-analyses and randomized trials (PARTNER, SURTAVI [Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients]²⁷), showed that TAVI was comparable or, in some cases, superior to SAVR in terms of 30-day survival.^22,25 Unfortunately, the risk of stroke, bleeding, and acute renal failure was found to be more common with TAVI; on the other hand, this method was associated with shorter hospitalization and faster recovery.^25,28

Long-term results

The NOTION (Nordic Aortic Valve Intervention) study,²⁹ published in 2024, compared the 2 methods of AS treatment and presented 30-day results, as well as outcomes at 1, 5, and 10 years postprocedure.

The 30-day data showed that the patients undergoing TAVI often required pacemaker implantation (over 30% of all cases) and were at a higher risk of vascular complications, such as stroke.^28,29 After 1 year, the prevalence of secondary aortic valve regurgitation and symptomatic HF (New York Heart Association class II/III) was higher in the TAVI than the SAVR group.²¹ After 5 years, 8.2% of the patients who underwent TAVI also developed perivalvular leakage, but the other trends observed earlier remained unchanged.²⁵

Data from the 10-year mark in the NOTION study showed that survival, stroke, and myocardial infarction rates were similar in both groups.³⁰ Interestingly, TAVI was associated with a lower risk of structural valve degeneration, although the data are still limited and further observations and studies are needed to confirm this finding.⁷

Prosthesis durability

Bioprosthesis durability is a primary concern for all patients undergoing TAVI or SAVR with a biological prosthesis.

A few definitions are worth mentioning here. Bioprosthetic valve failure (BVF) is a failure of a bioprosthesis, including its functioning and problems with its structure (eg, structural valve deterioration [SVD]), hemodynamic failure caused by improper sizing or deterioration of the valve flow, or valve leaflet rupture or tear.¹¹

SVD is a progressive process of bioprosthesis degeneration, which over time leads to significant valve damage (eg, calcification), resulting in gradual deterioration of its function. It represents a common cause of secondary intervention in the long term.^7,25

TAVI may be associated with faster valve degeneration and earlier need for reoperation, especially in younger patients.^26,31 SAVR, on the other hand, ensures longer durability of bioprosthetic valves, but over time, SVD or BVF may also develop, potentially requiring replacement of the valve after approximately 15 to 20 years.^7,12,32 In both TAVI and SAVR procedures, it is crucial to monitor the condition of the implanted valve, especially in the long term, to ensure early detection of SVD and BVF and make a timely decision about reoperation, if necessary.^25,33

Common complications of transcatheter aortic valve implantation

The most common complications of the TAVI procedure include: 1) pacemaker implantation: TAVI can damage the electrical conducting system of the heart (interaction between the newly implanted prosthesis and atrioventricular node and bundle of His), requiring pacemaker implantation in a significant percentage of patients. In individuals undergoing SAVR, abnormalities in the heart rhythm are often temporary^4,8,11; 2) vascular complications: access site problems, such as bleeding, hematomas, and pseudoaneurysms are common in TAVI due to the insertion of a catheter^18,21; 3) bleeding: TAVI is associated with a higher risk of life-threatening bleeding than SAVR, particularly in the first 3 days after the procedure^29,34; 4) stroke: TAVI carries a higher risk of silent cerebral emboli than SAVR^20,35; 5) acute kidney injury (AKI): AKI is a known complication of TAVI, mostly due to the usage of a contrast agent during the procedure.³² However, the risk of AKI is lower in TAVI than in SAVR; 6) paravalvular leak: leakage around the new valve (eg, due to wrong sizing) occurs more frequently after TAVI than SAVR, requiring further intervention³³; 7) coronary occlusion: in rare cases, the new TAVI valve can block a coronary artery (eg, due to wrong placement or inadequate distances to the coronary artery outlets), potentially causing myocardial infarction and / or fatal outcomes.²⁸

Surgical aortic valve replacement–related complications

The most common complications of SAVR are: 1) stroke: SAVR carries a higher risk of stroke than TAVI, which is caused by external circulation of blood in SAVR patients³⁴; 2) AKI: AKI is more common with SAVR, likely due to the greater invasiveness of the procedure¹¹; 3) atrial fibrillation and other types of arrhythmia can occur after SAVR; they are usually transient and develop within a few days of the procedure¹⁰; 4) infection: SAVR carries a risk of infection, including wound infections, lung infections (eg, pneumonia), and heart valve infections¹¹; 5) blood clots: SAVR can lead to blood clot formation, potentially causing thromboembolism²¹; 6) bleeding: SAVR is associated with short, temporary postoperative bleeding, which requires chest tube drainage¹¹; 7) prolonged ventilation: in some patients, prolonged ventilation following SAVR may be required, as in the case of other cardiac surgical procedures.¹¹

Role of the heart team

The qualification process for TAVI and SAVR treatment should always be based on an individual patient analysis. The heart team should consist of a cardiologist, a cardiac surgeon, an interventional cardiologist, and an anesthesiologist. The therapeutic decision should take into account the current guidelines, the risk score calculated using the STS risk calculator or EuroSCORE II,⁸ as well as CT and echocardiography findings.^9,18 Main indications for SAVR include young patient age, presence of bicuspid aortic valve, active or previous endocarditis, thrombus in the left ventricle or aorta, contrast sensitivity, and unfavorable anatomy for TAVI (eg, low-lying coronary arteries).^5,10 TAVI is more often recommended for older patients with increased frailty (calculated by the clinical frailty scale), those with a porcelain aorta, deformed rib cage, or scoliosis, and individuals at a high surgical risk.^19,20

In some cases, the heart team could also decide to qualify the patient for a sutureless valve implantation or select the newest valve models with an expected prolonged durability.^13-17,36 In borderline patients, the trend to choose a bioprosthetic valve, which started decades ago, will likely continue.^14,36

Conclusions

Both SAVR and TAVI are effective methods of treating severe AS, and each of them has its unique advantages, disadvantages, and apparent limitations. The choice of the technique should be based on a comprehensive clinical assessment, the risk of the procedure, anatomical considerations, and patient preferences. In the era of an aging society and technological progress, the role of TAVI will systematically continue to grow, but in many cases, classic surgery remains necessary and irreplaceable. The key elements of treatment success remain an interdisciplinary cooperation and an individualized approach to the patient.

Correspondence to

Natalia Michalik, MD, Department of Cardiac Surgery, Vascular Surgery and Transplantology, St. John Paul II Hospital, ul. Prądnicka 80, 31-202 Kraków, Poland, phone: +48 12 614 32 22, email: natalia.mchalik@gmail.com

Received

June 17, 2025.

Revision accepted

July 18, 2025.

Published online

July 29, 2025.

Acknowledgments

None.

Contribution statement

All authors contributed to the conception and design of the study. Material preparation, data collection, and analysis were performed by NM, GF, and KB. The first draft of the manuscript was written by NM. GF and KB commented on the previous versions of the manuscript. All authors read and approved the final version of the manuscript.

AI statement

Artificial intelligence was not used in the preparation of this manuscript.

Conflict of interest

None declared.

How to cite

Michalik N, Filip G, Mędrzycki M, et al. Surgical aortic valve replacement vs transcatheter aortic valve implantation: the role of both techniques in the treatment of severe aortic stenosis. Prz Lek Jagiellonian Med Rev. 2025; 77: 19998. doi:10.20452/jmr.2025.19998

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