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Review

Treatment of the Aortic Valve in the Modern Era—A Review of TAVR vs. SAVR

by
Albert Dweck
1,
Brandon E. Ferrell
2,
Daniel Guttman
1,
Stephen M. Spindel
2 and
Tadahisa Sugiura
2,*
1
Albert Einstein College of Medicine, Bronx, NY 10461, USA
2
Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY 10467, USA
*
Author to whom correspondence should be addressed.
Surgeries 2025, 6(1), 4; https://doi.org/10.3390/surgeries6010004
Submission received: 19 November 2024 / Revised: 26 December 2024 / Accepted: 29 December 2024 / Published: 31 December 2024
(This article belongs to the Special Issue Cardiothoracic Surgery)
Versions Notes

Abstract

:
Aortic stenosis (AS) is the most common valve disease in developed countries, with severe cases traditionally managed through surgical aortic valve replacement (SAVR). More recently, transcatheter aortic valve replacement (TAVR) has been used as a less invasive alternative, especially for patients deemed high-risk for surgery. This review aims to compare SAVR and TAVR by examining the efficacy, patient selection criteria, complications, and evolving guidelines. SAVR is the preferred option for patients at low surgical risk or with anatomical challenges unsuitable for TAVR. It offers well-documented durability and favorable long-term survival. Conversely, TAVR has gained acceptance for intermediate- and high-risk patients, with shorter recovery times and reduced immediate postoperative risks. However, questions surrounding its long-term durability in younger populations persist. Complications differ between the approaches, with TAVR associated with vascular access injuries and arrhythmic events, while SAVR presents risks tied to open surgery. As clinical guidelines evolve, patient age, comorbidities, and life expectancy play critical roles in determining the optimal intervention. This review highlights the need for tailored treatment approaches, given the expanding indications and evolving evidence for both SAVR and TAVR in AS management.

1. Introduction

Aortic stenosis (AS) is the most common valvular disease in developed nations [1]. AS commonly presents with exertional dyspnea in earlier stages and symptoms may progress to angina, syncope, and heart failure such as dyspnea at rest, lower extremity edema, and orthopnea [2,3]. The progression of AS is highly variable, and valve replacement is the only effective treatment in symptomatic patients since no medical therapies have been proven to slow leaflet disease [4,5]. Traditionally, surgical aortic valve replacement (SAVR) has been the standard procedure for addressing severe aortic valve disease [6]. Once considered the gold standard, this procedure has demonstrated low operative mortality rates in experienced institutions, offering promising long-term outcomes. Long-term survival after SAVR is comparable in certain age groups such as in those aged greater than 70 [7,8].
Variables like age, gender, emergent replacement, decreased left ventricular function, hypertension, coronary artery disease, and prior reinterventions can have a negative effect on perioperative mortality [9]. These factors may also render certain patients ineligible for the procedure. Therefore, in 2002, transcatheter aortic valve replacement (TAVR) was created as a less invasive treatment for AS. Initially, it was deployed on patients considered high-risk for surgery given their comorbidities such as severe left ventricular dysfunction, end-stage renal failure, cirrhosis, and significant frailty. With positive findings arising from SAVR vs. TAVR comparative trials, this method has shown promise as an effective intervention for patients with low to intermediate surgical risk [10]. TAVR utilization more than doubled between 2015 and 2021, with a particularly notable increase among patients under 65, and has surpassed SAVR in the number of procedures performed annually [11].
The rapid adoption of TAVR underscores its transformative impact on aortic valve disease management, especially as studies continue to explore its efficacy across broader patient demographics. While TAVR offers a less invasive approach with shorter recovery times, questions remain regarding its long-term durability, particularly for younger patients. This review aims to compare SAVR and TAVR across key parameters—efficacy, patient selection, complications, and emerging indications—to provide a thorough understanding of each procedure’s role in treating aortic valve disease (Table 1). Through this analysis, we clarify the two approaches, discuss the risks and benefits, and review guideline recommendations.

2. Methods

This review combines findings from a comprehensive literature search utilizing the PubMed database. Studies were identified using a combination of search terms including “aortic stenosis”, “SAVR”, “TAVR”, “transcatheter aortic valve replacement”, “surgical aortic valve replacement”, “outcomes”, “complications”, and “guidelines”. The search was limited to articles published in English.
Inclusion criteria encompassed studies that directly compared SAVR and TAVR across various parameters, including efficacy, patient selection, complications, and long-term outcomes. Studies focused on advancements in valve replacement techniques, guideline updates, and emerging indications were also included.
Articles were reviewed for quality and relevance, with a focus on randomized controlled trials and systematic reviews. Guideline documents from major cardiovascular societies, including the American College of Cardiology (ACC) and the American Heart Association (AHA), were analyzed to summarize current recommendations.

3. SAVR Overview

3.1. History

For over six decades, SAVR has been the gold standard for treating severe aortic valve disease [12]. Since its establishment, SAVR has been an effective solution for valve replacement, with consistently positive outcomes that have continued to improve as the field advances [13]. At experienced institutions, in low-risk patients, the mortality rate for SAVR has been reported at approximately 0.5% to 1%, highlighting its efficacy and safety profile when performed under optimal conditions [7,14].
Studies have shown a marked reduction in morbidity and mortality following isolated SAVR, with a consistent decrease in index hospitalization mortality rates and progressive improvements over the years. This positive trend has been observed in patients older than 65, as well as in all classes of left ventricular ejection fraction (LVEF), in both genders, and in both high- and intermediate-low-risk patients [15]. Additionally, postoperative complications, such as new cerebrovascular accidents and the need for postoperative dialysis, have significantly declined over time [16].

3.2. Procedure Details

Median sternotomy or, less often, right thoracotomy, provides access to the mediastinum, allowing surgeons to operate on the aortic valve. The procedure requires cardiopulmonary bypass (CPB) which drains deoxygenated blood from the right atrium and returns oxygenated blood to the aorta, providing blood flow to the brain and body, as well as allowing for a bloodless operating field. A high potassium solution given directly to the heart causes temporary asystolic arrest, and the aorta is opened for surgery on the valve during electrocardiogram quiescence. Following the excision of the diseased valve, a prosthetic valve—either mechanical or bioprosthetic—is implanted with non-absorbable sutures. In younger patients, mechanical valves are preferred due to their durability, although they require lifelong anticoagulation which includes an increased risk of hemorrhagic and thromboembolic events [17]. In contrast, bioprosthetic valves, often derived from bovine or porcine tissue, offer the advantage of avoiding anticoagulation but have limited durability, especially in younger patients [18].
A partial or hemi-sternotomy is an alternative to full median sternotomy and is often the primary access for minimally invasive aortic valve replacement. This alternative shows no significant difference in postoperative adverse events or mortality. It has also been shown to reduce operative times and have similar lengths of recovery compared to full sternotomy [19]. Lastly, the Ross procedure, also known as the pulmonary autograft procedure, is another option for SAVR [20]. In this procedure, the patient’s pulmonary valve replaces the diseased aortic valve. To restore pulmonary valve function, a pulmonary allograft is used to replace the original pulmonary valve. Studies indicate that the Ross procedure remains effective for 15 to 20 years, offering a durable solution for aortic valve replacement in younger patients with AS [21]. When compared to mechanical valve replacement, the Ross procedure does not require anticoagulation, though the use of antiplatelet drugs is common. As a result, the Ross procedure offers a significant reduction in major bleeding and cerebrovascular events, along with improved freedom from valve-related mortality compared to mechanical valves. However, freedom from reintervention and long-term survival are similar between the procedures [22].

Small Aortic Annulus/Root Enlargement

High-pressure transvalvular gradients may occur after surgery despite normally functioning prostheses, commonly in patients with a small aortic annulus and a small-sized prosthetic valve. This patient-prosthesis mismatch is due to residual postoperative left ventricular outflow tract obstruction and results in ongoing AS symptoms, hospitalizations for heart failure exacerbation, and worsened long-term survival [23,24]. Several strategies have been developed to minimize postoperative gradients by enlarging a small aortic annulus via root enlargement methods such as the Nicks, the Manouguian, the Y-incision, and the Konno procedures. All involve transecting the aortic annulus and enlarging it via implantation of a prosthetic or bovine pericardial patch. In the Nicks and Manougian Procedures, the aortotomy is extended proximally into the noncoronary sinus and aortic annulus, into the aortomitral curtain, and often onto the anterior mitral leaflet. A triangular prosthetic or bovine pericardial patch is anastomosed here, creating a larger left ventricular outflow tract [25]. The Y-incision technique splits the aortic annulus horizontally below the left-noncoronary commissure allowing a rectangular patch to be anastomosed to the aortomitral curtain which then enlarges the annulus [26]. Lastly, the Konno Procedure is a more extensive approach commonly used in the pediatric population for congenital aortic stenosis or very small annuli. It enlarges the aortic annulus at the left-right commissure by splitting the annulus and extending the incision through the interventricular septum, followed by patch reconstruction [27].

3.3. Indications

SAVR is the preferred treatment for aortic stenosis in patients with low to intermediate surgical risk and in younger populations who benefit from the known durability of surgical valves.x It is particularly suited for patients with anatomical challenges such as bicuspid aortic valve, low coronary heights, and heavy calcification of the aortic annulus and left ventricular outflow tract [28]. Its versatility is effective in patients with comorbid conditions that complicate catheter-based approaches, including those with unsuitable vascular anatomy or coexisting cardiac conditions that may require additional surgical interventions. Additionally, it can also be used for certain indications, including early treatment in patients with moderate or asymptomatic stenosis, pure aortic regurgitation, and small aortic annulus.14 For patients without prohibitive surgical risk, SAVR offers a well-established and durable solution, especially given its track record for long-term survival rates comparable to age-matched control populations [29]. Lastly, SAVR’s direct access approach allows for precise valve placement, reducing the likelihood of paravalvular leaks [30].

3.4. Complications and Contraindications

Certain patients may be contraindicated for SAVR due to anatomical and physiological factors or due to increased perioperative risk. Prior mediastinal radiation or extensive calcification of the ascending aorta complicates SAVR from both technical and anatomical perspectives [31]. Comorbidities that increase perioperative risk include chronic obstructive pulmonary disease (COPD), home oxygen dependence, pulmonary hypertension, severe right ventricular dysfunction, and hepatic dysfunction. Additionally, patients with a life expectancy of less than one year, poor rehabilitation potential, or a Society of Thoracic Surgery predictive operative mortality score greater than 15% are generally considered unsuitable candidates for SAVR [6].
Studies have demonstrated that the incidence of in-hospital mortality and adverse neurologic events is significantly higher among patients of advanced age and those with elevated surgical risk [32]. SAVR carries certain risks due to its invasive nature, with complications often arising from the open-heart approach and the use of cardiopulmonary bypass (CPB). The risk of postoperative bleeding is between 8 and 31% necessitating blood transfusions, while the 1-year risk of disabling stroke is 3% [33,34,35]. Arrhythmias, particularly atrial fibrillation, are also frequently seen following SAVR, sometimes requiring long-term anticoagulation, and there is a 3% risk of permanent pacemaker implantation [36,37]. Additionally, the sternotomy incision poses a 1–5% risk of sternal wound infections, especially in patients with underlying conditions such as diabetes or obesity [38,39]. Acute kidney injury (AKI) is another concern, as altered renal perfusion during CPB can impact kidney function, with older patients and those with preexisting renal impairment being at higher risk [40]. In addition, women undergoing SAVR have a higher 30-day mortality compared to men (4.4% vs. 1.6%). This may be a result of women presenting at an older age and with more advanced heart failure symptoms compared to men [41]. However, long-term survival is similar between genders [42,43].

4. TAVR Overview

4.1. History

In 2002, TAVR was created as a less invasive treatment for aortic valve disease [44]. The first clinical trials comparing TAVR with SAVR focused on patients who were considered inoperable or at high surgical risk [45]. Therefore, TAVR was initially approved and applied for use in this specific patient group, providing a treatment option for those who were not suitable for SAVR. Given its less invasive nature, there is a push for expanding the use of TAVR for treating AS in intermediate- and low-risk patients. However, long-term research specifically focused on the safety and efficacy of TAVR is still ongoing. Two randomized clinical trials—PARTNER 3 and EVOLUT Low Risk—compared TAVR to SAVR outcomes in low-risk patients. These trials demonstrated the non-inferiority of TAVR versus SAVR, with primary endpoints such as all-cause mortality analyzed at one-year follow-up in PARTNER 3 and two-year follow-up in the EVOLUT Low-Risk trial [46,47]. In August 2019, the FDA approved an expanded indication for certain TAVR devices to include patients with severe aortic stenosis (AS) who are at low risk of death or major complications during surgery [48]. This approval marked a significant step in broadening access to TAVR, making it a viable option for a wider range of patients beyond the high-risk population. Since then, the PARTNER 3 study has assessed outcomes over 5 years and found no difference between the SAVR and TAVR groups in two primary composite outcomes which included factors like death, stroke, and rehospitalization related to the valve [49]. Similarly, the EVOLUT trial investigated 4-year outcomes and found a 26% relative reduction in the hazard of death or disabling stroke with TAVR compared with SAVR [50].

4.2. Procedure Details

TAVR is typically performed through transfemoral access. In this approach, a wire is passed through the femoral artery, traverses the aortic valve, and sits in the left ventricle. Next, a compressed bioprosthetic valve is inserted along this wire and expanded within the diseased aortic valve, restoring normal valve function [51]. For patients who are not candidates for the transfemoral route due to unfavorable iliofemoral artery characteristics such as stenoses and severe tortuosity, alternative access options include trans-subclavian access, transthoracic approaches (transaortic retrograde and transapical antegrade), and the transcarotid approach [52,53,54]. The choice of access route is determined by the valve type, as well as operator and institutional experience.
The TAVR implantation process consists of key preoperative planning. Aortic root imaging—such as preprocedural computed tomography angiography and echocardiography—guides the alignment of the aortic annulus for the most accurate TAVR implantation. For most valves, a standard coplanar view is used to align all three aortic cusps equidistantly [55]. However, a “cusp overlap” view is often preferred for self-expanding valves, as it isolates the noncoronary cusp and elongates the left ventricular outflow tract, enhancing accuracy in valve sizing and positioning [56].
In certain cases, such as in patients with a bicuspid aortic valve, extensive aortic valve calcification, difficulty in valve crossing, or extremely high transvalvular gradients, balloon aortic valvuloplasty may be performed before TAVR valve delivery to further prepare the native valve for implantation [57,58]. Following this, the transcatheter heart valve is delivered and positioned within the aortic annulus. Fluoroscopy and echocardiography are employed to confirm the correct positioning of the valve [59]. Any paravalvular leaks are assessed using echocardiography, angiography, and pressure measurements [60,61]. Lastly, if the initial implantation position is suboptimal—such as when there is paravalvular regurgitation, new or worsened atrioventricular block, or coronary artery impingement—and the valve is of a recapturable and repositionable type, repositioning can be performed [62].

4.3. Indications

TAVR is recommended for patients of any age who are deemed at high or prohibitive risk for SAVR and have suitable vascular anatomy, provided their life expectancy exceeds one year [63]. It is generally favored in older patients (those over 80 years), especially for those with a life expectancy of fewer than 10 years, irrespective of surgical risk category. It is also recommended for patients over 80 years old at high or prohibitive surgical risk but with an expected survival of at least one year. For symptomatic patients aged 65 to 80, either TAVR or SAVR may be appropriate, depending on individual patient characteristics, procedural risk, and institutional experience. TAVR is also considered suitable for asymptomatic patients under age 80 with a reduced ejection fraction (<50%) [64].

4.4. Complications and Contraindications

TAVR is generally not recommended for patients under 65 or those with a life expectancy greater than 20 years due to uncertainties surrounding the long-term durability of TAVR devices [65,66]. Comorbidities that increase risk include severe COPD or the need for home oxygen therapy, pulmonary hypertension, severe right ventricular dysfunction, hepatic dysfunction, and frailty. For patients with a Society of Thoracic Surgery predictive operative mortality score greater than 15%, life expectancy under one year, or who are poor candidates for rehabilitation, TAVR may also pose increased risks related to futility.
Periprocedural complications are often associated with vascular access and include injury at the arterial entry site, trauma along the arterial tree, ventricular perforation, and potential failure of vascular closure devices [67,68]. Complications during valve deployment include malpositioning, coronary compromise, and annular rupture, all of which can critically impact patient outcomes [69]. Valve function issues, such as paravalvular leak, may also arise, along with organ injuries, including stroke, myocardial ischemia or injury, and acute kidney injury [70,71]. Arrhythmias are common as well, with a high-degree heart block being a notable risk [72]. In the long term, patients may experience issues such as aortic regurgitation, prosthetic valve thrombosis, late bleeding, and prosthetic valve endocarditis [73]. Compared to SAVR, TAVR generally shows lower rates of major bleeding and atrial fibrillation but carries a higher risk of short-term reintervention, pacemaker implantation, and paravalvular aortic regurgitation. Women undergoing TAVR have higher rates of vascular and bleeding complications as well as an increased risk of stroke when compared to men [74,75]. However, the rate of moderate to severe paravalvular regurgitation as well as the all-cause mortality at 1 year has been shown to be lower for women than for men [76,77,78].

4.5. TAVR Explant

Some patients who undergo TAVR develop serious complications with the implanted prosthesis that can only be salvaged with a surgical approach [79]. Given the growing population receiving TAVR and the current expansion of its indications to relatively lower-risk patients, the number of patients who require an open surgical procedure may rise following the index TAVR procedure. Some indications for explantation include structural valve degeneration, severe paravalvular leak, TAVR periprocedural complications, prosthetic valve endocarditis, and bridge-to-definitive surgery [80]. Studies have underscored the high-risk nature of these patients, both perioperatively and in the months following surgery. One study showed that many patients required urgent or emergency procedures (53.1%), with aortic root replacement performed in a subset of cases (13.4%), and the majority undergoing concomitant cardiac procedures (54.6%). These patients also experience an increased risk of stroke (18.7% at 1 year) and 30-day mortality (13.1%) [81].
This trend raises important concerns, as younger and lower-risk patients are undergoing TAVR without a comprehensive understanding of potential long-term complications and the likelihood of needing further invasive interventions. Lifelong management of AS patients is important. Therefore, educating patients on the implications of undergoing TAVR and the long-term associations is key to enduring success.

5. Current Guidelines

Valvular heart disease management recommendations were recently updated. The 2020 American College of Cardiology (ACC) and American Heart Association (AHA) Guidelines for the Management of Patients with Valvular Heart Disease note the most current guidelines on SAVR and TAVR. These guidelines provide comprehensive recommendations on the evaluation and treatment of aortic valve disease, including indications for SAVR and TAVR, patient selection criteria, and procedural considerations.
Specifically, when evaluating patient populations by age, patients less than 65 years of age or with a life expectancy of more than 20 years, SAVR is the recommended management both for symptomatic and asymptomatic patients with severe AS. Between the ages of 65 and 80, in patients with no contraindication to TAVR due to anatomic variations, either SAVR or TAVR may be appropriate management of AS and the mode of valve replacement should be a joint decision between the patient and provider while considering valve durability and the patient’s life expectancy. For patients who are >80 years old, or for those who have a life expectancy of less than 10 years, TAVR is the recommended management for symptomatic patients with severe AS as long as there are no anatomical contraindications. For asymptomatic patients with severe AS but with an EF < 50%, the management should be the same as that for the symptomatic patient in the same age group. However, if the patient is asymptomatic with severe AS but also has either an abnormal exercise test, a stenosis that is classified as very severe, rapid progression of the stenosis, or an elevated BNP, then SAVR is recommended over TAVR [82].

6. Conclusions

The choice between SAVR and TAVR for severe aortic stenosis requires a personalized approach, guided by patient age, risk profile, and anatomical considerations. With growing evidence supporting TAVR’s efficacy and expanded indications, it now serves as a viable alternative for many high- and intermediate-risk patients. As TAVR technology advances, ongoing research will further refine patient selection and long-term outcomes, ensuring optimal care for diverse patient populations.

Author Contributions

Conceptualization, B.E.F. and T.S.; writing—original draft preparation, A.D. and D.G.; writing—review, and editing, B.E.F., S.M.S. and T.S.; supervision, T.S. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. TAVR vs. SAVR Comparison.
Table 1. TAVR vs. SAVR Comparison.
CategoryTAVRSAVR
InvasivenessPercutaneous. Open surgery requiring median sternotomy, hemi-sternotomy, or thoracotomy.
Patient RecoveryShorter recovery times, less postoperative pain.Longer time in hospital and recovery.
DurabilityLimited long-term data; concerns about durability in younger patients (<65 years).Proven long-term durability, especially with mechanical valves.
ComplicationsHigher risk of vascular injuries, paravalvular leaks, arrhythmias (e.g., heart block requiring pacemaker).
Lower risk of major bleeding and atrial fibrillation.		Risks from open-heart surgery, including bleeding, stroke, atrial fibrillation, sternal wound infections, and acute kidney injury.
Long-term anticoagulation (mechanical valves).
Patient SelectionBest suited for older patients (>80 years) or those at high or prohibitive surgical risk.
Increasing use in intermediate- and low-risk patients.		Preferred for younger patients (<65 years) or those with long life expectancy (>20 years).
Recommended for patients with anatomical challenges (e.g., bicuspid valves, heavy calcification).
Procedural RisksRisks include valve malpositioning, coronary compromise, and annular rupture.
Requires precise imaging for valve placement.		Higher perioperative mortality and neurologic events in high-risk patients.
Risks tied to cardiopulmonary bypass, including embolic events and low cardiac output.
Reoperation/ExplantMay require surgical explantation due to structural valve degeneration, paravalvular leak, or endocarditis.
Valve-in-valve TAVR option for future replacement in select patients.		May require surgical explantation due to structural valve degeneration (biological), paravalvular leak, or endocarditis.
Valve-in-valve TAVR option for future replacement of biological valves in select patients.
Procedure VersatilityLimited by vascular anatomy and procedural complexity (e.g., bicuspid valves, small annuli).
Less suitable for patients needing additional cardiac procedures.		Can address complex anatomical challenges (e.g., low coronary heights, small annuli).
Suitable for concomitant surgical interventions (e.g., CABG, mitral intervention, aortic aneurysm).
Current GuidelinesRecommended for high-risk or inoperable patients.
Expanding indications for intermediate- and low-risk groups based on recent trials (PARTNER 3, EVOLUT Low Risk).		Recommended for low-risk patients and younger individuals.
Preferred for those with severe AS and associated high-risk anatomical or functional findings.
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Dweck, A.; Ferrell, B.E.; Guttman, D.; Spindel, S.M.; Sugiura, T. Treatment of the Aortic Valve in the Modern Era—A Review of TAVR vs. SAVR. Surgeries 2025, 6, 4. https://doi.org/10.3390/surgeries6010004

AMA Style

Dweck A, Ferrell BE, Guttman D, Spindel SM, Sugiura T. Treatment of the Aortic Valve in the Modern Era—A Review of TAVR vs. SAVR. Surgeries. 2025; 6(1):4. https://doi.org/10.3390/surgeries6010004

Chicago/Turabian Style

Dweck, Albert, Brandon E. Ferrell, Daniel Guttman, Stephen M. Spindel, and Tadahisa Sugiura. 2025. "Treatment of the Aortic Valve in the Modern Era—A Review of TAVR vs. SAVR" Surgeries 6, no. 1: 4. https://doi.org/10.3390/surgeries6010004

APA Style

Dweck, A., Ferrell, B. E., Guttman, D., Spindel, S. M., & Sugiura, T. (2025). Treatment of the Aortic Valve in the Modern Era—A Review of TAVR vs. SAVR. Surgeries, 6(1), 4. https://doi.org/10.3390/surgeries6010004

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