Written by Peter Liu
Spoon Feed
Current RCT meta-analyses of transcatheter aortic valve replacement (TAVR) vs. surgical aortic valve replacement (SAVR) in patients with low surgical risk show a mortality benefit with TAVR.
Scenarios where TAVR is an optimal strategy continue to expand
Not long ago, surgical aortic valve replacement (SAVR) was once the standard for treating severe aortic stenosis (AS), with transcatheter aortic valve replacement (TAVR) reserved for patients at prohibitive surgical risk. Today, TAVR has become more commonly used, expanding into moderate-risk populations and encroaching on traditionally SAVR-treated low-risk patients.
A recent meta-analysis of six RCTs (n=5,341) comparing TAVR to SAVR in low-risk patients found that TAVR was associated with reduced 5-year all-cause mortality (HR 0.80; 95%CI 0.66–0.97; P=0.02) and death or disabling stroke (HR 0.81; 95%CI 0.68–0.96; P=0.01), with no significant difference in stroke rates. TAVR, however, resulted in higher rates of pacemaker implantation, vascular complications, and paravalvular leak, while SAVR had higher rates of bleeding, atrial fibrillation, and acute kidney injury. Only two studies included follow-up to 5 years (n=1,280), and survival curves converge at this time point, raising questions about better long-term outcomes with SAVR. Given TAVR’s higher incidence of paravalvular leak and the greater durability of surgical valves, SAVR likely remains the preferred option for patients with longer life expectancy.
How does this change my practice?
In general, all patients that might benefit from AVR should be referred to a multidisciplinary specialty team to consider all treatment options: medical treatment alone, TAVR, SAVR, or palliative care. It now appears that a decision to undergo SAVR is limited to situations where multiple factors align to prompt a valve team to recommend such an invasive procedure. These factors currently include patient factors (e.g. young age or long life expectancy), anatomical factors (e.g. issues with a femoral artery approach or with mitral regurgitation), and surgical risk (e.g. low surgical risk).
Source
Transcatheter vs Surgical Aortic Valve Replacement in Lower-Risk Patients: An Updated Meta-Analysis of Randomized Controlled Trials. J Am Coll Cardiol. 2025 Mar 11;85(9):926-940. doi: 10.1016/j.jacc.2024.12.031. PMID: 40044297
