European Journal of Cardiovascular Medicine

Aortic stenosis (AS) is one of the most common and serious valve diseases in developed countries, especially affecting elderly individuals. ^[1]  Characterized by a narrowing of the aortic valve opening, it leads to increased cardiac afterload, progressive left ventricular hypertrophy, and eventually heart failure if left untreated. ^[2] The traditional treatment for severe symptomatic AS has long been Surgical Aortic Valve Replacement (SAVR), a well-established procedure offering durable results and symptomatic relief. ^[3]

However, over the past two decades, Transcatheter Aortic Valve Replacement (TAVR) has emerged as a less invasive alternative, particularly suitable for patients at high surgical risk. ^[4] Since its first successful human implantation in 2002, TAVR has gained significant traction worldwide, with numerous randomized clinical trials and registries supporting its efficacy and safety in various risk cohorts. ^[5]

Multiple landmark trials, including PARTNER and Core Valve studies, have demonstrated non-inferiority or even superiority of TAVR compared to SAVR in selected populations. ^[6] These trials also highlighted differences in procedural complications, recovery profiles, and valve hemodynamics between the two methods. ^[7]  While TAVR patients typically benefit from shorter hospital stays and faster recovery, they may also face higher rates of vascular complications and paravalvular leak. ^[8]

Patient selection remains a cornerstone in deciding between TAVR and SAVR. Factors such as age, frailty, comorbidities, anatomical suitability, and life expectancy play critical roles in this decision-making process. ^[9] The development of Heart Teams—multidisciplinary teams involving cardiologists, surgeons, anesthetists, and radiologists—has improved the individualized assessment and optimized outcomes. ^[10]

Despite the increasing use of TAVR, particularly among high- and intermediate-risk patients, SAVR continues to be recommended for younger, low-risk individuals due to the longer-term durability of surgical bioprosthetic valves. ^[11] The recent trend in expanding TAVR to low-risk cohorts has sparked debates regarding long-term outcomes, prosthetic valve durability, and the implications for younger patients with longer life expectancy. ^[12]

This article aims to provide a comprehensive comparison of TAVR and SAVR based on clinical outcomes, complication profiles, and postoperative recovery, supported by data from real-world cohorts and historical studies. Through a prospective analysis, we aim to guide clinical decision-making and highlight the advantages and limitations of each approach in treating severe AS.

This prospective and observational study was conducted at a tertiary cardiac care center, analyzing medical records from January 2024 and June 2025. The study focused on patients with a confirmed diagnosis of severe aortic stenosis (AS), defined echocardiographically as an aortic valve area (AVA) <1.0 cm², mean pressure gradient >40 mmHg, or peak aortic jet velocity >4.0 m/s. Data were retrieved from institutional databases and validated by two independent reviewers.

Study Population A total of 420 patients was included. Patients were divided into two groups based on the intervention received: Surgical Aortic Valve Replacement (SAVR, n=230) and Transcatheter Aortic Valve Replacement (TAVR, n=190). All patients underwent comprehensive preoperative assessment including echocardiography, cardiac catheterization, and CT angiography when applicable.

Inclusion Criteria

• Age ≥65 years
• Diagnosed severe symptomatic aortic stenosis
• EuroSCORE II or STS risk assessment available
• Eligibility for both SAVR and TAVR as per Heart Team evaluation
• Informed consent for procedure and data use

Exclusion Criteria

• Active infective endocarditis
• Bicuspid aortic valve morphology
• Prior surgical or transcatheter valve replacement
• Concomitant severe mitral or tricuspid valve disease requiring intervention
• Life expectancy <1 year due to non-cardiac comorbidities

Procedures SAVR was performed via median sternotomy under general anesthesia with cardiopulmonary bypass. TAVR procedures were performed using transfemoral access in 85% of cases, with general or conscious sedation based on clinical stability. Balloon-expandable and self-expanding valves were used according to anatomical suitability and operator preference.

Data Collection and Outcomes Preoperative, intraoperative, and postoperative variables were collected, including baseline demographics, comorbidities, procedural times, ICU and total hospital stay, complications, and echocardiographic outcomes. Primary outcomes included 30-day mortality, major vascular events, stroke, permanent pacemaker implantation, paravalvular leak, and functional status (NYHA class) at discharge.

In table 1, AVR patients were significantly older (81.4 vs 73.2 years, p<0.001). STS Score: Higher in TAVR group (8.1% vs 4.5%, p<0.001), meaning higher surgical risk.

Table 1: Baseline Characteristics

Table 2: Procedural Characteristics

In table 2, Much shorter for TAVR (90 vs 150 min, p<0.001). ICU Stay & Hospital Stay: Both significantly shorter for TAVR (ICU 1.2 vs 3.6 days; total stay 4.8 vs 9.1 days, p<0.001). Conversion to surgery: Rare in TAVR (2.1%).

Table 3: Early Postoperative Outcomes

In table 3, No significant difference (Mortality 3.7% vs 4.3%, Stroke 2.6% vs 2.2%). Acute Kidney Injury: No difference (p=0.49). Major Bleeding: Significantly lower in TAVR (5.3% vs 9.6%, p=0.03).

Table 4: Device-Related Complications

In table 4, Higher in TAVR (12.1% vs 4.3%, p<0.001). Paravalvular Leak: Higher in TAVR (6.8% vs 1.3%, p<0.001). Valve Malposition: More frequent in TAVR (2.9% vs 0.4%, p=0.02).

Table 5: Functional Status at Discharge

Table 6: 1-Year Follow-Up (Composite Events)

This study provides a comprehensive comparison of TAVR and SAVR outcomes in patients with severe aortic stenosis, drawing on real-world prospective data. The results support and expand upon prior randomized trials and registries, offering valuable insights into patient selection, procedural benefits, and complications.

Our findings align closely with the PARTNER trial (2011), which established the non-inferiority of TAVR in high-risk surgical patients. ^[13] Similarly, the CoreValve trial (2014) reported lower all-cause mortality in TAVR compared to SAVR among high-risk cohorts. ^[14] In our study, while 30-day mortality rates were statistically similar, TAVR offered reduced hospital stay and ICU time, which may translate into lower healthcare utilization and better patient satisfaction.

However, the incidence of device-related complications, particularly permanent pacemaker implantation and paravalvular leak, was higher in the TAVR group. This observation mirrors outcomes from the FRANCE 2 registry and other observational cohorts. ^[15-20] The increased rate of conduction abnormalities requiring pacemaker placement is predominantly attributed to the anatomical proximity of the aortic valve annulus to the cardiac conduction system, especially when using self-expanding valves.

Bleeding complications, in contrast, were more frequent in SAVR patients, likely due to the invasiveness of open-heart surgery and cardiopulmonary bypass. These findings reinforce the less traumatic nature of TAVR and its appeal in frail or elderly patients with multiple comorbidities.

Long-term valve durability remains a major concern in younger populations. Although structural valve deterioration (SVD) rates were low in both groups at one-year follow-up, current literature suggests that surgical bioprosthetic valves have a proven track record of durability beyond 10-15 years, whereas TAVR prostheses lack comparable long-term data. ^[21] Thus, while TAVR may be favorable in elderly or high-risk individuals, SAVR remains the preferred choice for low-risk patients with longer life expectancy.

Our functional outcome data (NYHA classification) showed no significant difference at discharge, which supports findings from the SURTAVI and NOTION trials, where both procedures led to improved symptomatic relief and functional capacity. ^[22] Importantly, the individualized approach using Heart Team evaluation allows appropriate selection based on anatomy, frailty, and patient preferences.

This study’s strengths lie in its large sample size and real-world setting, which enhances external validity. However, several limitations exist. Additionally, our follow-up was limited to one year; hence, longer-term comparisons of durability and reintervention rates could not be assessed.

In summary, TAVR offers a less invasive, equally effective alternative to SAVR in selected populations, with faster recovery and comparable survival. However, higher device-related complications and uncertainty around long-term valve performance necessitate careful patient selection. Our findings reinforce the current guideline approach of tailoring valve therapy based on surgical risk, anatomy, and life expectancy.

This study reinforces that both TAVR and SAVR are effective treatment modalities for patients with severe symptomatic aortic stenosis, each with distinct advantages and limitations. TAVR is particularly beneficial for elderly patients or those with high surgical risk, offering shorter hospital stays, faster recovery, and comparable short-term survival outcomes. However, its association with higher rates of conduction disturbances, paravalvular leak, and limited long-term durability data necessitates cautious application, especially in younger or low-risk patients. Conversely, SAVR continues to provide a durable solution with lower device-related complication rates, making it the preferred choice in younger populations with longer life expectancy and lower surgical risk. The use of a multidisciplinary Heart Team remains essential in guiding optimal treatment decisions tailored to individual patient profiles.

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