Severe aortic stenosis: TAVI versus surgical valve replacement

Overview and guideline basis

Aortic stenosis is a slow narrowing of the aortic valve. Increasing fibrosis and calcification carry it from mild to severe obstruction, and progression speeds up as the haemodynamic severity rises.^[1]

Degenerative cusp calcification is the most common cause in developed countries, and prevalence is rising quickly as populations age. Bicuspid (or, rarely, unicuspid) valves degenerate earlier, dominate among younger patients needing valve replacement, and often come with a dilated aortic root or ascending aorta. In low- and middle-income countries, rheumatic AS remains frequent and usually accompanies rheumatic mitral disease.^[1]

^{[10] [1] [8] [9]}

The 2025 guideline still names underdiagnosis and undertreatment as concerns.^[1] In a prospective registry by Frey et al. of newly diagnosed severe AS in 23 tertiary hospitals across 9 European countries, a decision for intervention was made in only 76.2% despite a class I recommendation in the 2017 ESC guideline. Most patients already presented at an advanced stage.^[8]

Pathophysiology

Two pressure loads, one ventricle. The narrowed valve is the first load. Systemic hypertension adds a second pressure load, which lowers forward stroke volume and the transaortic gradient compared with the normotensive state.^[2] If a study recorded while the patient was hypertensive suggests only moderate AS, ACC/AHA advises repeating the measurements once blood pressure is better controlled.^[2]

What happens to the ventricle. In the ACC/AHA staging, asymptomatic severe AS (C1) shows LV diastolic dysfunction, mild LV hypertrophy and normal LVEF. Symptomatic high-gradient disease (D1) shows diastolic dysfunction and hypertrophy, and pulmonary hypertension may be present.^[2] Paradoxical low-flow AS (D3) has increased relative wall thickness, a small LV chamber with low stroke volume, restrictive filling and LVEF of 50% or more.^[2]

Why a low LVEF can recover. The depressed LVEF in many patients comes from excessive afterload, and LV function improves after valve replacement in such patients. If LV dysfunction is not caused by afterload mismatch, survival is still improved, likely because of the reduced afterload, but recovery of LV function and symptoms might not be complete.^[2] For low-flow, low-gradient AS with reduced LVEF, ESC/EACTS 2025 adds the limit: improvement is unlikely if the main cause is fibrosis from myocardial infarction or cardiomyopathy.^[1]

Sex differences. The pathophysiology of AS seems to differ by sex, with women having less calcium and more fibrosis. Concentric hypertrophy is more frequent in women, giving a higher LVEF with a smaller cavity and stroke volume. Paradoxical low-flow, low-gradient AS is therefore frequent in women and may contribute to underdiagnosis and delayed intervention.^[1]

^{[2] [1]}

Natural history

• Progression rate (ACC/AHA). In moderate AS (velocity 3.0–3.9 m/s), velocity rises by an average of 0.3 m/s, mean gradient by 7 mm Hg and valve area falls by 0.1 cm² each year. Individual variability is marked, with faster progression in older patients and with more severe leaflet calcification.^[2]
• Asymptomatic severe AS (ACC/AHA 2020). With velocity of 4.0 m/s or more, event-free survival is only 30% to 50% at 2 years. With normal LV systolic function, sudden death risk is low (below 1% per year) when patients are followed prospectively and report symptoms promptly.^[2]
• Very severe AS. In a prospective cohort by Rosenhek et al. of 116 consecutive asymptomatic patients with very severe isolated AS (peak velocity 5.0 m/s or more), event-free survival was 64% at 1 year and 3% at 6 years. Most events were a new indication for valve replacement (90 of 96).^[11]
• After symptoms appear. ESC/EACTS 2025 notes that once symptoms occur, the risk of sudden cardiac death rises sharply unless the valve is treated.^[1]

No drug has been shown to slow the valve. ESC/EACTS 2025 states that no medical therapy has been shown to influence the natural history of AS to date, and ACC/AHA 2020 found no data supporting statins to prevent progression.^[1][2] ESC/EACTS 2025 advises treating coexistent hypertension to avoid extra afterload, preferably with renin-angiotensin system blockers, titrated carefully to avoid symptomatic hypotension.^[1]

Clinical presentation

The most common first symptom is exertional breathlessness or reduced exercise tolerance.^[2] In the ACC/AHA staging, symptomatic severe high-gradient AS (D1) lists exertional dyspnoea, decreased exercise tolerance or heart failure, exertional angina, and exertional syncope or presyncope. The low-gradient stages D2 and D3 list heart failure, angina, and syncope or presyncope.^[2]

Patients may adapt. Because the valve narrows slowly, they may limit their activity over years and deny symptoms that exercise testing can still unmask.^[1] In the registry by Frey et al., 80.3% were symptomatic: breathlessness 91.0%, dizziness 30.2% and chest pain 28.9%. Left ventricular hypertrophy was present in 62.1% and LVEF below 50% in 27.3%.^[8]

• Women and men. ESC/EACTS 2025 notes that women with severe AS present more often with breathlessness, and men with severe AS more often with angina, presumably because coronary disease is more common.^[1]
• Acute decompensation. ESC/EACTS 2025 notes that acute decompensated AS accounts for up to 25% of AS hospital admissions, but only 1.6% to 3.2% of these patients present in cardiogenic shock.^[1]

Bedside assessment

In the meta-analysis by Shellenberger et al., a diminished second heart sound and a delayed carotid upstroke helped detect AS of at least moderate severity, and absence of a systolic murmur radiating to the neck ruled against it. In the cohort by Munt et al., examination findings correlated with stenosis severity, but echo was still needed to exclude severe obstruction reliably when it was suspected. The Shellenberger meta-analysis had enough data from seven observational studies to assess three findings.^[57][58]

^[57]

• Quality of the evidence. This meta-analysis rests on low-quality observational evidence, and gives the two positive signs only moderate accuracy; absence of a murmur radiating to the neck is equally accurate in excluding at least moderate AS.^[57]
• A bedside rule (Etchells et al.). In 124 consecutive hospital inpatients referred for echo, moderate or severe AS was defined as valve area 1.2 cm² or less or peak instantaneous gradient 25 mm Hg or more. Absence of a murmur over the right clavicle ruled it out (LR 0.10). The rule used four associated findings: slow carotid upstroke, reduced carotid volume, maximal murmur at the second right intercostal space, and a soft second heart sound. Three or four of them ruled AS in (LR 40).^[59]
• Signs track severity but miss the cut-off. In 123 initially asymptomatic subjects with aortic stenosis (mean age 63 years) followed for a mean of 2.5 years in the cohort by Munt et al., jet velocity correlated with murmur intensity and timing, a single second heart sound, and carotid upstroke delay and amplitude. Yet no finding had both high sensitivity and high specificity for severe obstruction.^[58] Carotid upstroke amplitude was the only examination finding that independently predicted outcome.^[58]

ACC/AHA 2020 notes that in adults, physical examination may not be accurate for diagnosing or grading AS.^[2] Munt et al. concluded that echocardiography is still needed to exclude severe obstruction reliably when it is suspected.^[58] ESC/EACTS 2025 calls echocardiography key to confirming the diagnosis and assessing the anatomy and severity of the stenosis.^[1] In known AS, ACC/AHA advises a repeat echo when the murmur becomes louder or peaks later in systole, A2 becomes soft or absent, or new symptoms could be due to the valve. It also advises one with increased haemodynamic demands, such as non-cardiac surgery, pregnancy, systemic infection, anaemia or gastrointestinal bleeding.^[2]

ESC/EACTS 2025 calls a meticulous history, a comprehensive examination with auscultation, documentation of clinical signs of heart failure (such as dyspnoea, impaired physical capacity and fatigue, peripheral oedema and pleural effusion) and a systematic frailty assessment crucial.^[1] In FRAILTY-AVR, a prospective cohort of older adults undergoing TAVI or SAVR, the four-item Essential Frailty Toolset (lower-extremity weakness, cognitive impairment, anaemia, hypoalbuminaemia) was the strongest of 7 frailty scales compared for predicting death at 1 year (adjusted OR 3.72).^[44]

Differential diagnosis

Outflow obstruction is not always valvular. The 2024 AHA/ACC HCM guideline lists valvular or subvalvular stenosis among the causes of obstruction that can cause diagnostic dilemmas with hypertrophic cardiomyopathy.^[64] Management changes with the site of obstruction: valvular, dynamic LVOT obstruction, fixed subvalvular, or midcavitary.^[64]

^[1]

When a patient has symptomatic obstructive HCM and also needs surgery for valvular AS, myectomy by experienced operators lets all lesions be corrected in one operation.^[64] No held source gave a quotable approach to supravalvular stenosis, so it is not covered here.

Grading severity

ESC/EACTS 2025 categories

Grading rests on mean gradient (the most robust parameter), peak velocity and effective valve area.^[1] When these disagree, AS may be further categorised by flow using stroke volume index; 35 mL/m² is the conventional threshold between low and normal flow.^[1]

^{[1] [1]}

ACC/AHA 2020 stages

ACC/AHA stages AS from A (at risk) and B (progressive) to C (asymptomatic severe) and D (symptomatic severe).^[2] In stages C1, C2 and D1, severe AS is a Vmax of 4 m/s or more or a mean gradient of 40 mm Hg or more; ACC/AHA grades severity by velocity or gradient when transaortic flow is normal. Valve area is typically 1.0 cm² or less; in C1 and C2 it is not required to define severe AS, and in D1 it may be larger with mixed AS/AR.^[2] Very severe AS is a Vmax of 5 m/s or more or a mean gradient of 60 mm Hg or more.^[2]

^[2]

Investigations that settle a discordant valve

• CT aortic valve calcium score. ESC/EACTS 2025: above 2000 AU in men and above 1200 AU in women indicates severe AS (sensitivity and specificity about 85%). Severe AS is unlikely below 1600 AU in men and below 800 AU in women.^[1] ACC/AHA 2020 thresholds are 2000 in men and 1300 in women.^[2]
• Calcium-score pitfalls. Cautious interpretation is required when severe AS can develop without pronounced calcification, for example with bicuspid valves, concomitant amyloidosis or predominantly fibrotic stenosis associated with post-rheumatic, radiation-induced or inflammatory disease.^[1]
• Dobutamine stress echo. In low-flow, low-gradient AS with reduced LVEF, it can help to discriminate pseudo-severe from true severe AS when flow reserve is present (stroke volume rises by 20% or more).^[1] ACC/AHA describes a fixed valve area: velocity rises to 4 m/s or more (mean gradient 40 mm Hg or more) at any flow rate while area stays at or below 1.0 cm², with a maximum dobutamine dose of 20 mcg/kg per minute.^[2]
• Projected valve area. In a study by Annabi et al. of 186 patients with low-LVEF, low-flow, low-gradient AS undergoing dobutamine stress echo, AS severity was independently corroborated (valve inspection at surgery and/or CT calcium score) in 87; 50 of these (57%) had true-severe AS. A projected valve area of 1 cm² or less classified severity correctly in 70%. That beat the peak-stress gradient, peak-stress valve area and their combination (48%, 60% and 47%). It was also strongly associated with mortality under conservative management.^[7]
• Velocity ratio. When other parameters are equivocal, the velocity ratio may assist evaluation; a ratio below 0.25 suggests that severe AS is highly likely (ESC/EACTS 2025 text).^[1]
• Complementary tests. In low-flow, low-gradient AS with reduced LVEF, CT calcium scoring and dobutamine stress echo provide complementary information; if findings are equivocal, an integrated assessment of all clinical, morphological and haemodynamic factors is required.^[1]

^[1]

Exercise testing, biomarkers and imaging markers

• Exercise testing. The ESC/EACTS 2025 text recommends it for risk stratification in asymptomatic severe AS. It can unmask symptoms and haemodynamic intolerance, defined there as a blood pressure fall of more than 20 mm Hg.^[1] ACC/AHA cites a high rate of symptom onset within 1 to 2 years (about 60% to 80%) in patients without overt symptoms who show either of two findings. The findings are a systolic fall of 10 mm Hg or more from baseline to peak exercise, or a significant decrease in exercise tolerance compared with age and sex normal standards. ACC/AHA adds that management without an appropriate blood pressure rise on exercise is less clear; elective AVR decisions then consider surgical risk, patient preferences and clinical factors such as age and comorbid conditions.^[2]
• Avoid in symptomatic AS. ACC/AHA 2020: exercise testing is avoided in symptomatic AS because of a high risk of complications, including syncope, ventricular tachycardia and death.^[2]
• Natriuretic peptides. ESC/EACTS 2025 notes that they can be used to arbitrate the source of symptoms when there are several potential causes, and help identify high-risk asymptomatic AS that may benefit from early intervention.^[1] ACC/AHA 2020 cites a cohort of 387 asymptomatic adults with severe AS in which a BNP above 300 pg/mL (3 times normal) carried a hazard ratio of 7.38 for AS-related events over 5 years.^[2]
• Global longitudinal strain. A GLS threshold of −15% may contribute to identifying patients with severe asymptomatic AS at increased risk of clinical deterioration or premature death (ESC/EACTS 2025).^[1]
• Cardiac amyloidosis. Transthyretin amyloidosis may coexist with AS in older patients. Patients with transthyretin amyloidosis and concomitant severe AS usually still benefit from valve intervention.^[1]

Planning tests

• Cardiac CT before TAVI. It is the preferred tool to assess valve anatomy, including annulus size, root and ascending aorta, valve and LVOT calcium, coronary ostial height, fluoroscopic projections and vascular access.^[1]
• Coronary assessment. The ESC/EACTS 2025 text recommends it to evaluate the need for revascularisation when valve surgery or an intervention is planned. For chronic coronary syndrome, CT coronary angiography is recommended before valve intervention when the pre-test likelihood of obstructive coronary disease is 50% or lower (class I, level B); invasive angiography is recommended when it is above 50% (class I, level C).^[1] In elderly TAVI candidates, CT sensitivity for obstructive coronary disease is high (95% to 97%), but specificity is modest (68% to 73%). In TAVI candidates with chronic coronary syndrome, omitting invasive angiography should be considered if procedural planning CT angiography is of sufficient quality to rule out significant coronary disease (class IIa, level B).^[1]
• LV catheterisation. The ESC/EACTS 2025 text does not recommend it unless symptoms and signs suggest severe AS and non-invasive tests are inconclusive.^[1]

Resuscitation: the decompensated patient

• Balloon aortic valvuloplasty has largely been replaced by TAVI in this setting, because of the high risk of severe aortic regurgitation and death in the acute setting.^[1] ESC/EACTS 2025: balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in haemodynamically unstable patients and, if feasible, in severe AS requiring urgent high-risk non-cardiac surgery (class IIb, level C). It carries significant risks of acute complications.^[1]
• Direct TAVI. A meta-analysis by Doma et al. of 9 studies comparing TAVI with and without temporizing valvuloplasty in severe AS included 59,205 patients, 4.3% of whom had valvuloplasty before TAVI. In it, direct TAVI was associated with lower 30-day mortality than valvuloplasty followed by TAVI (RR 0.62); the authors call for randomised confirmation.^[46]
• Do not wait for drugs. In the ESC/EACTS 2025 text, in symptomatic severe AS with heart failure, starting medical therapy or a temporary improvement should not delay intervention.^[1]

Indications for intervention

Symptomatic severe AS (ESC/EACTS 2025)

^[1]

In low-flow, low-gradient AS with reduced LVEF, absent flow reserve is associated with increased surgical and long-term mortality. Even so, in this group both TAVI and SAVR improved LVEF and clinical outcomes in observational studies.^[1] In a meta-analysis by Soltani Moghadam et al. of 19 observational studies (20 493 TAVI patients), 5-year mortality was higher with classical (HR 1.92) and paradoxical (HR 1.20) low-flow, low-gradient AS than with high-gradient AS.^[41]

Asymptomatic severe AS (ESC/EACTS 2025)

1. Unmask symptoms first. In roughly one-third of asymptomatic patients with severe AS, exercise testing can uncover symptoms or reduced exercise capacity due to AS; treat them as symptomatic.^[1]
2. LVEF below 50%. Intervention is recommended when there is no other cause (class I, level B).^[1]
3. Severe high-gradient AS, LVEF 50% or more, low procedural risk. Intervention should be considered as an alternative to close active surveillance, with absence of symptoms confirmed by a normal exercise test if feasible (class IIa, level A).^[1]
4. Severe AS, LVEF 50% or more, low procedural risk and one high-risk feature. Intervention should be considered (class IIa, level B). The features are very severe AS (mean gradient ≥60 mm Hg or Vmax above 5.0 m/s), or severe valve calcification, ideally on CT, with Vmax progression of 0.3 m/s or more per year. They also include BNP or NT-proBNP more than three times the age- and sex-corrected normal range, confirmed on repeat measurement without other explanation, or LVEF below 55% without another cause.^[1]
5. Sustained blood pressure fall above 20 mm Hg during exercise testing. Intervention should be considered (class IIa, level C).^[1]
6. Service factors count. In the ESC/EACTS 2025 text, restricted local resources or long waiting lists favour early intervention.^[1]

^[1]

Randomised trials of early intervention (trial reports)

^[1]

How to read these trials:

• EARLY TAVR. ESC/EACTS 2025 notes that the benefit was driven by the 26.2% of the surveillance group who converted to TAVI within 6 months of randomisation because of symptoms or adverse prognostic factors. It also reports no significant difference in stroke or all-cause mortality over 5-year follow-up.^[1] In the trial report, during a median follow-up of 3.8 years, 87.0% of the surveillance group underwent valve replacement.^[31]
• The surgical trials. ESC/EACTS 2025 notes that RECOVERY and AVATAR were small, enrolled selected younger patients at low surgical risk (mean ages 64 and 67 years) and mostly very severe AS.^[1]
• EVOLVED. ESC/EACTS 2025 notes that it was underpowered, and median time to intervention in the early-intervention arm was prolonged to 5 months. The trial reported a wide 95% CI around the primary end point, with further research needed. As a secondary end point, unplanned AS admissions were lower (6% vs 17%; HR 0.37), but 7 of 9 prespecified secondary end points showed no significant difference.^[1][55]
• Pooled evidence. Meta-analysis of the four trials showed significantly fewer unplanned cardiovascular or heart failure admissions and strokes, but no significant reduction in all-cause or cardiovascular mortality. ESC/EACTS 2025 notes that the pooled trials were heterogeneous and the analysis was study-level.^[1]

ACC/AHA 2020 position

Concomitant SAVR. ESC/EACTS 2025 recommends SAVR in severe AS when CABG or ascending aortic surgery is performed (class I, level C). SAVR should be considered in moderate AS during those operations (class IIa, level C), with moderate AS defined as valve area 1.0–1.5 cm² or mean gradient 25–40 mm Hg in normal-flow conditions. Clinical assessment is essential to decide whether SAVR is appropriate for the individual patient.^[1] In a cohort study by Ito et al. of moderate AS defined by valve area alone (above 1.0 and up to 1.5 cm²), mortality was 2.43 times that of an age- and sex-matched general population.^[47]

Choosing TAVI or SAVR

The Heart Team

^[1]

• Patient preference plays a central role. The Heart Team recommendation should still rest on objective medical factors, chiefly the relative risks and benefits of each procedure.^[1]
• Shared decision. The process ends with a shared decision between the treating team and the informed patient and relatives.^[1]
• Urgent cases. The need for Heart Team review should not paralyse decisions; ad hoc discussion is appropriate in urgent situations.^[1]
• Formal ESC/EACTS 2025 recommendations. Aortic valve interventions are recommended in Heart Valve Centres that report local expertise and outcome data, with on-site interventional cardiology and cardiac surgical programmes and a structured collaborative Heart Team (class I, level C). The mode of intervention is recommended to rest on Heart Team assessment of individual clinical, anatomical and procedural characteristics, incorporating lifetime management and estimated life expectancy (class I, level C).^[1]
• ACC/AHA 2020: all patients with severe valve disease being considered for intervention should be evaluated by a multidisciplinary team, with referral to or consultation with a Primary or Comprehensive Valve Center.^[2]

Age, life expectancy and the two guidelines

The mode of intervention depends on estimated life expectancy, expected valve durability, patient preference and each option's trade-offs.^[1] Age is a pragmatic surrogate for life expectancy. Younger patients with AS seem to have shorter life expectancy than the general population even after valve replacement, whereas life expectancy almost normalises after treatment in older cohorts.^[1]

^{[1] [2]}

The ESC/EACTS cut-off rests on lifetime management and the scarcity of randomised data below 70 years, where representation in RCTs is low.^[1] RCT patients were mostly men, and patients with low-flow, low-gradient AS or adverse anatomical characteristics (including bicuspid valves or complex coronary disease) were excluded per protocol.^[1]

^{[1] [2]}

Mechanical or biological? ESC/EACTS 2025 recommends a mechanical valve according to the desire of the informed patient if there is no contraindication to long-term anticoagulation, and a bioprosthesis according to the desire of the informed patient (both class I, level C). A bioprosthesis is also recommended when good-quality VKA anticoagulation is unlikely, bleeding risk is high or estimated life expectancy is short (class I, level C). A mechanical valve should be considered with an estimated long life expectancy and no contraindication to long-term anticoagulation (class IIa, level B), and with a mechanical valve already in another position (class IIa, level C). It may be considered with a clear indication for long-term anticoagulation (class IIb, level C). For the aortic position, a mechanical valve should be considered below 60 years (class IIa, level C) and a bioprosthesis above 65 years (class IIa, level C). A bioprosthesis should also be considered in women contemplating pregnancy (class IIa, level C). Life expectancy should be estimated according to age, sex, comorbidities, ethnicity and geographical area.^[1] ACC/AHA 2020 favours a mechanical valve below 50 years unless anticoagulation is unwanted, unmonitorable or contraindicated, and calls a bioprosthesis reasonable above 65 years; between 50 and 65 years it notes continuing uncertainty and debate about the valve type.^[2] ESC/EACTS 2025 describes the Ross procedure as a valuable surgical option in young patients with prolonged life expectancy in whom anticoagulation is undesirable or contraindicated, but it is complex and about 15% need reintervention within 15 years.^[1]

Anatomy and access

^[1]

• Features that raise surgical risk. ESC/EACTS 2025 notes that unfavourable characteristics such as porcelain aorta, mobile aortic atheroma and previous mediastinal radiation therapy increase the surgical risk, and therefore may favour transcatheter treatment options.^[1]
• Relative contraindications. LV thrombus and infective endocarditis are relative contraindications to TAVI.^[1]
• RCT advantages are largely transfemoral. The advantages of TAVI in RCTs are largely confined to transfemoral access.^[1] In the PARTNER 2 trial (2032 intermediate-risk patients with severe symptomatic AS), death or disabling stroke at 5 years did not differ significantly overall (47.9% vs 43.4%; HR 1.09). Patients had been stratified by intended access. In the transthoracic-access cohort, the primary end point of death or disabling stroke was higher after TAVI than after surgery (HR 1.32); in the transfemoral-access cohort it was similar (HR 1.02).^[25]
• When femoral access fails. SAVR remains preferred. Non-transfemoral TAVI (transaxillary, transcarotid, transcaval, transinnominate or transapical) should be considered in patients unsuitable for surgery and for transfemoral access (class IIa, level B); the supporting data are observational.^[1] ACC/AHA says SAVR or palliative care should enter the discussion.^[2]
• Less invasive surgery. Right anterior thoracotomy and upper hemisternotomy are being used increasingly.^[1]

Surgical risk and frailty

• Scores. EuroSCORE II and the STS-PROM score are the most commonly used systems to estimate surgical risk. In TAVI candidates they are less accurate and tend to overestimate risk.^[1]
• ACC/AHA risk categories. Low-risk SAVR must meet all of: STS-predicted mortality below 3%, no frailty, no cardiac or other major organ system compromise that is not expected to improve postoperatively, and no procedure-specific impediment. High risk is any one of: STS above 8%, ≤1 frailty index (moderate to severe), such compromise in 1 to 2 organ systems, or a possible procedure-specific impediment. Prohibitive risk is any one of: predicted risk of death or major morbidity (all-cause) above 50% at 30 days, two or more frailty indices (moderate to severe), such compromise in 3 or more organ systems, or a severe procedure-specific impediment.^[2][66][67] ACC/AHA notes that using the STS-PROM to predict risk in a given institution with reasonable reliability is appropriate only if institutional outcomes are within 1 standard deviation of the STS average observed/expected mortality ratio for the procedure; EuroSCORE II may also be considered.^[2] Frailty indices are the Katz Activities of Daily Living plus independent ambulation, and other scoring systems can be used to grade frailty. Major organ system compromise includes, for example, cardiac, kidney (chronic kidney disease stage 3 or worse), pulmonary, central nervous system, gastrointestinal, cancer and liver dysfunction. Impediments include tracheostomy, porcelain ascending aorta, chest malformation, an arterial coronary graft adherent to the posterior chest wall and radiation damage.^[2]
• What scores miss. A 2011 review noted that factors affecting mortality but not included in the logistic EuroSCORE or STS-PROM include liver disease, frailty, porcelain aorta and previous radiation.^[52]
• Frailty. Frailty, including nutritional state, is an important determinant of outcome after valve interventions.^[1]

The randomised evidence

^[1]

• Unsuitable for surgery. TAVI beat medical therapy, with five patients treated to prevent one death at 1 year.^[1]
• Across risk groups. RCTs then showed non-inferiority of TAVI compared with SAVR at high, intermediate and low surgical risk, with comparable longer-term outcomes over follow-up of 4 to 10 years.^[1]
• Meta-analysis. TAVI reduced all-cause death and disabling stroke at 1 year in low-risk patients. There was no difference at longer follow-up, or at intermediate or high risk.^[1]
• DEDICATE (German, mean age 74 years, median STS 1.8%) also showed lower death from any cause at 1 year, a component of its primary outcome (TAVI 2.6% vs SAVR 6.2%).^[3][1]
• RHEIA randomised 443 women (mean age 73 years) to balloon-expandable transfemoral TAVI or surgery. The benefit came mainly from fewer rehospitalisations.^[1][56]

Longer follow-up (TAVI versus surgery). PARTNER 3 (low-risk, severe symptomatic AS) at 7 years showed no significant difference in either primary end point. The first (death, stroke or procedure-, valve- or heart failure-related rehospitalisation) was 34.6% versus 37.2% (difference −2.6 points; 95% CI −9.0 to 3.7), and the second had a win ratio of 1.04 (95% CI 0.84 to 1.30). Among its echocardiographic end points, mean gradients were 13.1 versus 12.1 mm Hg.^[18] Evolut Low Risk at 5 years: death or disabling stroke 15.5% versus 16.4% (P = 0.47).^[16] SURTAVI at 5 years (a prespecified secondary end point): death or disabling stroke was similar, 31.3% versus 30.8% (HR 1.02; P = .85).^[21]

Non-randomised comparison. One study compared intermediate-risk patients treated with SAPIEN 3 TAVI in the PARTNER 2 SAPIEN 3 Intermediate-risk Registry with the surgical arm of the PARTNER 2A trial, using 1:1 propensity-score matching. TAVI patients were enrolled in the registry in 2014 and surgical patients in the trial from 2011 through 2013, so the groups were not randomised to each other. At 10 years, all-cause mortality was similar: 83.4% after TAVI and 82.3% after surgery (HR 1.01; P = 0.82).^[27]

Complications and trade-offs

^[1]

• Pacemakers: how often. In the meta-analysis by Ullah et al. of 78 studies (31 261 patients), the mean pacemaker rate after TAVI was 18.9% per study, ranging from 0.16% to 51%.^[60] In the network meta-analysis by Ravaux et al., pooled rates were 19.2% with balloon-expandable, 24.7% with self-expanding and 34.8% with mechanically expandable valves.^[62] In the Ravaux analysis, balloon-expandable valves had 39% and 62% lower rates than self-expanding and mechanically expandable valves.^[62] Among the prespecified secondary 5-year outcomes of SURTAVI, new pacemakers were 39.1% after TAVI versus 15.1% after surgery.^[21]
• Pacemakers: who gets one. In the Ullah meta-analysis, predictors were male sex, baseline atrioventricular conduction delay, intraprocedural atrioventricular block and mechanically expandable or self-expanding valves.^[60] Its pooled unadjusted odds ratios (Ullah et al.) included 2.48 for baseline right bundle branch block and 4.17 for periprocedural AV block.^[60] An earlier systematic review by van Rosendael et al. added LVOT calcification, balloon valvuloplasty and implantation depth.^[33]
• Pacemakers: does it matter later? In the meta-analysis by Zito et al. of 31 observational studies (mean follow-up 22 months), a pacemaker after TAVI was linked with higher all-cause death, the primary endpoint (RR 1.18). Of the Zito secondary endpoints, heart failure readmission was higher (RR 1.32), while stroke and myocardial infarction were not affected.^[61] ESC/EACTS 2025 describes the long-term data on new pacemakers or left bundle branch block as conflicting.^[1]
• Paravalvular regurgitation. In the review by van Wely et al., any degree is associated with higher overall and cardiovascular mortality. The same review notes conflicting results for mild regurgitation, and that most studies in the meta-analyses were unadjusted cohorts, with a risk of confounding.^[34] Predictors include annular eccentricity, severe valve calcification, bicuspid valves and prosthesis type; balloon-expandable devices are associated with less leak. The review adds prosthesis undersizing and implantation depth (too deep or too shallow).^[34] It can be treated by post-dilation, a vascular plug or a second device.^[34] ESC/EACTS 2025 notes that although paravalvular leak has been associated with adverse clinical outcomes, it does not seem to change the TAVI-versus-SAVR comparison of clinical outcomes in RCTs.^[1] For clinically significant paravalvular leak, ESC/EACTS 2025 recommends that the choice between transcatheter and surgical closure is based on Heart Team evaluation, including patient risk, leak morphology and local expertise (class I, level C). Reoperation is recommended if a paravalvular leak is related to endocarditis, or causes haemolysis requiring repeated blood transfusion or leading to heart failure symptoms (class I, level C). Transcatheter closure should be considered for suitable leaks with clinically significant regurgitation and/or haemolysis (class IIa, level B).^[1]
• Valve choice in practice. In the 1-year CHOICE follow-up, which had limited statistical power (241 high-risk patients with symptomatic severe AS), more-than-mild paravalvular regurgitation was 1.1% with the balloon-expandable Edwards SAPIEN XT versus 12.1% with the self-expandable Medtronic CoreValve. Clinical outcomes with the two valve types were not statistically significantly different.^[53][33] In a prespecified secondary analysis of the 621 women with small annuli in SMART, the coprimary clinical end point (death, disabling stroke or heart failure rehospitalisation) through 12 months was similar with self-expanding and balloon-expandable valves (9.4% vs 11.8%; P = .35). The coprimary valve function end point, bioprosthetic valve dysfunction, was lower with self-expanding valves (8.4% vs 41.8%).^[48]
• Recovery and quality of life. TAVI brings quicker recovery, shorter stays and faster quality-of-life gains.^[1] In PARTNER 3, mean KCCQ-OS was 16.0 points better with TAVI than surgery at 1 month; at 12 months it remained better, by 1.8 points.^[49]

Hypo-attenuated leaflet thickening (HALT)

• Prevalence. CT detects HALT in 10% to 30% of aortic bioprostheses, depending on antithrombotic therapy, definition, timing and valve type.^[1]
• No routine screening. In the ESC/EACTS 2025 text, its clinical significance is uncertain, so routine CT to look for HALT is not indicated.^[1]
• When to treat. In bioprosthetic valve thrombosis, ESC/EACTS 2025 recommends anticoagulation with a VKA before considering reintervention (class I, level B). Oral anticoagulation should be considered for leaflet thickening with reduced leaflet motion leading to elevated gradients, at least until resolution (class IIa, level B).^[1]

Antithrombotic therapy after valve replacement

^[1]

GALILEO randomised 1644 patients without an established indication for oral anticoagulation after successful TAVI to rivaroxaban 10 mg daily (with aspirin 75–100 mg daily for the first 3 months) or aspirin 75–100 mg daily (with clopidogrel 75 mg daily for the first 3 months).^[38] ESC/EACTS 2025 notes that it was halted prematurely because of an increased risk of death or thromboembolic complications and of bleeding with the rivaroxaban strategy; the trial report cites safety concerns.^[1][38] The primary efficacy outcome, death or a first thromboembolic event, occurred at 9.8 per 100 person-years with the rivaroxaban strategy versus 7.2 with the antiplatelet strategy (HR 1.35). The primary safety outcome, major, disabling or life-threatening bleeding, occurred at 4.3 versus 2.8 per 100 person-years (HR 1.50; 95% CI 0.95 to 2.37; P = 0.08).^[38]

Lifetime management

When estimated life expectancy exceeds the assumed valve durability, ESC/EACTS 2025 calls a meticulous CT-based anatomical analysis at the index procedure paramount. Based on individual assessment, the following measures should be considered.^[1]

^[1]

• Durability. ESC/EACTS 2025 states that available data do not suggest systematic differences in durability between TAVI and SAVR. As ESC/EACTS 2025 summarises, RCTs and observational studies have reported comparable SVD-related valve failure up to 10 years, although potential selection and survival bias, variable SVD definitions, limited follow-up, differential attrition, competing risk of death and mixed surgical valve types may limit direct comparison.^[1] In NOTION at 10 years, the primary composite of all-cause mortality, stroke or myocardial infarction was 65.5% after both TAVI and SAVR (HR 1.0). Among the NOTION bioprosthesis outcomes, severe structural deterioration was lower after TAVI (1.5% vs 10.0%; P = .02), while bioprosthetic valve failure was similar (9.7% vs 13.8%; P = .4). NOTION defined severe structural deterioration as a transprosthetic gradient of 30 mm Hg or more with a rise of 20 mm Hg or more, or severe new intraprosthetic regurgitation. Bioprosthetic valve failure combined valve-related or unexplained death after valve dysfunction, aortic valve reintervention, or severe structural deterioration.^[28] In an ad hoc analysis of PARTNER 3 (low-risk patients with symptomatic severe AS) at 7 years, all-cause bioprosthetic valve failure (6.9% vs 7.5%) and SVD-related failure (3.9% vs 5.3%) were low and similar after TAVI and surgery.^[50]
• Leaflet thrombosis. In the same ad hoc PARTNER 3 analysis, stage 2 or 3 thrombosis-related valve dysfunction (subclinical and clinical) was more frequent after TAVI (5.2% vs 0.9%). Most events occurred within 3 years and few progressed to valve failure.^[50]
• Redo options. ESC/EACTS 2025 recommends reintervention in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis (class I, level C), and reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction if surgical risk is low (class IIa, level C). Valve-in-valve TAVI is associated with lower peri-procedural risk than redo SAVR.^[1] For an aortic bioprosthesis with significant valve dysfunction, ESC/EACTS 2025 says transfemoral valve-in-valve implantation should be considered at intermediate or high surgical risk with suitable anatomical and prosthesis features, as assessed by the Heart Team (class IIa, level B).^[1] It raises the risk of severe prosthesis-patient mismatch, especially TAV-in-SAV, and coronary access may be difficult or impossible afterwards in a relevant proportion of patients, especially after TAV-in-TAV.^[1]
• Surgical explant of a TAVI valve. It is rare (below 1% of TAVI procedures) but carries early mortality as high as 12% to 17%.^[1]

Special situations

Bicuspid AS. TAVI is harder in bicuspid valves because of asymmetric calcification, an elliptical annulus and unstandardised sizing.^[1] Heavy cusp calcification, especially with a calcified raphe, is associated with increased risk of aortic root injury, paravalvular leak and mortality after TAVI. Bicuspid patients were excluded from almost all landmark TAVI-versus-SAVR trials.^[1]

In the NOTION 2 trial, the composite of all-cause death, stroke, or valve- or heart failure-related rehospitalisation at 1 year was numerically more frequent (seven versus two events) in an underpowered subgroup of 100 patients with bicuspid valves. The hazard ratio was 3.8 (95% CI 0.8–18.5; P = 0.07).^[1]

ESC/EACTS 2025: SAVR remains the primary treatment for stenotic bicuspid valves, particularly if patients are young or have coexistent aortopathy or unfavourable valve morphology. TAVI may be considered for severe bicuspid AS at increased surgical risk if anatomy is suitable (class IIb, level B).^[1]

Coronary disease. Under ESC/EACTS 2025, in chronic coronary syndrome with a primary indication for valve surgery, CABG is recommended for stenoses of 70% or more (class I, level C; 50% or more can be considered for left main). In the same setting, CABG should be considered for stenoses of 50% to 70% (class IIa, level C).^[1] With a primary indication for TAVI, PCI should be considered for stenoses of 90% or more in segments with a reference diameter of 2.5 mm or more (class IIa, level B). With a primary indication for a transcatheter valve intervention, PCI may be considered for stenoses of 70% or more in proximal segments of main vessels (class IIb, level B).^[1] Although conclusive evidence is still lacking, non-complex disease can be handled with CABG or PCI, while complex disease favours CABG.^[1] Invasive functional assessment (such as FFR) may be of limited value in severe AS, because the valve alters coronary haemodynamics.^[1] In patients with valve disease presenting with acute coronary syndrome, treatment decisions should be made according to the most recent ESC Guidelines.^[1]

Small annulus. A small annulus relative to body size raises the risk of prosthesis-patient mismatch. Annular enlargement allows a larger surgical valve, but it is technically complex, should be done in experienced centres, and its benefit must be balanced against a possibly higher risk of operative mortality. Supra-annular transcatheter valves reduce mismatch, though randomised long-term data on clinical outcomes and valve durability are pending.^[1]

Women. Women are less likely to be referred to a cardiologist and investigated.^[1] In women, RHEIA showed lower 1-year death, stroke or valve-, procedure- or heart failure-related rehospitalisation with transfemoral TAVI than with surgery. ESC/EACTS 2025 notes that the benefit was driven mainly by fewer rehospitalisations for valve- or procedure-related symptoms or worsening heart failure.^[56][1]

Pregnancy. ESC/EACTS 2025 lists conditions that need to be corrected before recommending pregnancy; they include severe AS with symptoms, an abnormal exercise test or LV systolic dysfunction.^[1] In AS, pregnancy is generally well tolerated when prior exercise tolerance was normal, even in severe AS, but heart failure has been reported in up to 25% of symptomatic patients. If symptoms persist despite diuretics, TAVI seems the preferred option in very selected patients, though evidence is lacking.^[1]

Non-cardiac surgery. In symptomatic severe AS needing urgent high-risk non-cardiac surgery, the ESC/EACTS 2025 text says TAVI or balloon valvuloplasty should be considered before surgery in critical AS, weighing the risk of acute severe aortic regurgitation after valvuloplasty. Its formal row says balloon valvotomy may be considered as a bridge to SAVR or TAVI in haemodynamically unstable patients and, if feasible, in severe AS requiring urgent high-risk non-cardiac surgery (class IIb, level C). In symptomatic severe AS where surgery can be deferred, a pre-operative Heart Team evaluation decides between SAVR and TAVI; the key messages recommend valve intervention before elective non-cardiac surgery.^[1]

Cancer. In active or stable cancer with severe AS, both TAVI and SAVR can be considered according to life expectancy, age, prognosis and disability after cancer treatment. Involve the treating oncologist to avoid futility.^[1]

Follow-up and prognosis

The follow-up intervals and heart failure advice below are from the ESC/EACTS 2025 text.^[1]

• Asymptomatic severe AS. Review at least every 6 months to detect early symptoms and echo changes, especially in LVEF.^[1]
• Moderate degenerative AS. Its prognosis may be worse than previously thought, particularly with significant valve calcification; re-evaluate at least annually.^[1]
• Mild AS. Younger patients without significant calcification may be seen every 2 to 3 years.^[1]
• After valve replacement. An early echo within the first weeks is recommended to document baseline prosthetic valve function. The ESC/EACTS 2025 text recommends clinical review and echo annually with a bioprosthesis, and whenever symptoms or signs suggest valve dysfunction.^[1]
• Heart failure therapy. With persisting heart failure or reduced LVEF, start medical therapy before the valve procedure and up-titrate it afterwards.^[1]
• Surgical outcomes. In the low-risk PARTNER 3 surgical arm, 5-year all-cause mortality was 9.0%.^[15]

Australia and New Zealand

High-yield summary

• Grading. ESC/EACTS 2025: high-gradient AS (mean gradient ≥40 mm Hg, Vmax ≥4.0 m/s, AVA ≤1 cm² [≤0.6 cm²/m²]) is severe irrespective of LV function and flow. Low flow is conventionally SVi ≤35 mL/m², although sex-specific thresholds have been proposed; low-flow cases are split by LVEF 50%.^[1]
• Calcium score for severe AS. ESC/EACTS: above 2000 AU in men and above 1200 AU in women (sensitivity and specificity about 85%). ESC/EACTS requires cautious interpretation when severe AS can occur without pronounced calcification, such as bicuspid valves, concomitant amyloidosis or predominantly fibrotic stenosis associated with post-rheumatic, radiation-induced or inflammatory disease.^[1] ACC/AHA: sex-specific thresholds for severe AS are 2000 AU in men and 1300 AU in women.^[2]
• Symptomatic severe AS. ESC/EACTS 2025: intervention is recommended in high-gradient AS (class I, level B); the text strongly recommends early intervention if life expectancy exceeds 1 year. In low-flow, low-gradient AS, intervention is recommended with LVEF below 50% (class I, level B) and should be considered with LVEF of 50% or more (class IIa, level B), each after careful confirmation that AS is severe. With preserved LVEF, other explanations such as measurement error, uncontrolled blood pressure and conditions lowering stroke volume must be carefully excluded.^[1]
• Asymptomatic severe AS. ESC/EACTS 2025: intervention is recommended when LVEF is below 50% without another cause (class I, level B). In asymptomatic high-gradient AS (confirmed by a normal exercise test, if feasible) with LVEF of 50% or more at low procedural risk, intervention should be considered as an alternative to close active surveillance (class IIa, level A). In asymptomatic severe AS with LVEF of 50% or more and low procedural risk, intervention should also be considered if one listed parameter is present (class IIa, level B). The parameters are very severe AS (mean gradient ≥60 mm Hg or Vmax above 5.0 m/s) or severe calcification (ideally on CT) with Vmax progression of 0.3 m/s or more per year. They also include markedly elevated BNP or NT-proBNP (more than three times the age- and sex-corrected normal range, confirmed on repeat without other explanation), or LVEF below 55% without another cause. In asymptomatic severe AS, intervention should be considered with a sustained blood pressure fall above 20 mm Hg during exercise testing (class IIa, level C).^[1]
• Route. ESC/EACTS 2025 recommends SAVR below 70 years at low surgical risk (STS-PROM and EuroSCORE II below 4%, plus Heart Team assessment) (class I, level B) and TAVI from 70 years with tricuspid AS if the anatomy is suitable (transfemoral access, annulus dimensions, device landing-zone calcification pattern and coronary obstruction risk) (class I, level A). For all remaining bioprosthesis candidates, SAVR or TAVI is recommended according to Heart Team assessment (class I, level B). The mode of intervention is recommended to be based on Heart Team assessment of clinical, anatomical and procedural characteristics, lifetime management and estimated life expectancy (class I, level C). Non-transfemoral TAVI should be considered in patients unsuitable for surgery and transfemoral access (class IIa, level B). Aortic valve interventions are recommended in Heart Valve Centres that report local expertise and outcomes, with on-site interventional cardiology and cardiac surgery and a structured collaborative Heart Team (class I, level C). Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVI in haemodynamically unstable patients, and if feasible before urgent high-risk non-cardiac surgery in severe AS (class IIb, level C). In severe bicuspid AS, TAVI may be considered at increased surgical risk if the anatomy is suitable (class IIb, level B). For adults in whom bioprosthetic AVR is appropriate, ACC/AHA 2020 considers it most prudent, based on the published evidence, to recommend SAVR below 65 years unless life expectancy is limited by comorbid cardiac or non-cardiac conditions, and calls both routes effective from 65 to 80 years in symptomatic severe AS. ACC/AHA notes that the TAVI-versus-SAVR RCTs enrolled high-velocity severe AS (stage D1). ACC/AHA calls the less robust observational and registry data on TAVI for symptomatic low-flow, low-gradient severe AS (stages D2 and D3) encouraging, and makes the same recommendations for symptomatic patients with confirmed severe AS regardless of flow rate.^[1][2]
• Bicuspid AS. ESC/EACTS 2025: SAVR remains primary, particularly in young patients or with aortopathy or unfavourable morphology; TAVI may be considered at increased surgical risk with suitable anatomy (class IIb, level B).^[1]
• After TAVI. ESC/EACTS 2025, without an anticoagulation indication: low-dose aspirin is recommended for 12 months (class I, level A), long-term low-dose aspirin after the first 12 months should be considered (class IIa, level C), routine oral anticoagulation is not recommended (class III, level A), and DAPT to prevent thrombosis is not recommended unless there is a clear indication (class III, level B).^[1] With an existing anticoagulation indication, oral anticoagulation is recommended (class I, level B), and POPular TAVI cohort B showed less bleeding over 1 month or 1 year with the anticoagulant alone than with clopidogrel added for 3 months.^[1][37]
• Durability. ESC/EACTS 2025 text: available data do not suggest a systematic durability difference; RCTs and observational studies have reported comparable SVD-related valve failure up to 10 years, although potential selection and survival bias, variable SVD definitions, limited follow-up, differential attrition, competing risk of death and mixed surgical valve types may limit direct comparison.^[1]

References55ShowHide

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