How should I decide between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR)?

Decision Algorithm for TAVI vs SAVR

The choice between TAVI and surgical AVR is primarily determined by patient age and life expectancy, with SAVR recommended for patients <65 years, either procedure acceptable for ages 65-80 years, and TAVI preferred for patients >80 years. 1

Age-Based Decision Framework

Patients <65 Years or Life Expectancy >20 Years

• SAVR is the definitive recommendation due to proven long-term valve durability extending beyond 20 years, while robust TAVI durability data only extends to 5 years. 1
• Recent real-world data from California shows TAVI use in patients ≤60 years is associated with 2.5-fold increased hazard of 5-year mortality compared to SAVR, despite TAVI rates inappropriately increasing from 7.2% to 45.7% between 2013-2021. 2
• The only exception is when life expectancy is <10 years due to comorbid conditions, in which case TAVI becomes acceptable. 1

Patients 65-80 Years

• Either SAVR or transfemoral TAVI is acceptable after shared decision-making, balancing patient longevity against valve durability. 1
• Key considerations favoring TAVI include: 1
  • Lower 1-year mortality (RR 0.67) in lower-risk patients 3
  • Reduced risk of atrial fibrillation, major bleeding, and acute kidney injury 1, 3
  • Shorter hospital stay and faster recovery 1
• Key considerations favoring SAVR include: 1
  • Lower rates of paravalvular leak
  • Less need for permanent pacemaker (3.4% vs 14.9%) 4
  • Lower valve reintervention rates
  • Established long-term durability data
• Independent predictors favoring TAVI in this age group: older age within the range, COPD, previous stroke, prior CABG. 5
• Independent predictors favoring SAVR: vascular disease, clinical urgency requiring concomitant cardiac procedures. 5

Patients >80 Years or Life Expectancy <10 Years

• Transfemoral TAVI is the preferred recommendation over SAVR, as valve durability (proven to 5+ years) likely exceeds remaining life expectancy. 1
• For women at age 80, average life expectancy is 10 additional years; for men, 8 years. 1
• SAVR utilization in patients >80 years appropriately decreased from 13.1% to 1.6% between 2016-2019, with TAVI now used in >97% of cases. 5

Anatomic and Risk-Based Modifiers

High or Prohibitive Surgical Risk (Any Age)

• TAVI is recommended if predicted post-TAVI survival is >12 months with acceptable quality of life, regardless of age. 1
• High risk defined as: STS score >8%, frailty, ≥2 major organ system compromise, or procedure-specific impediments. 1

Anatomic Contraindications to Transfemoral TAVI

• SAVR is recommended when valve/vascular anatomy unsuitable for transfemoral approach, including: 1
  • Inadequate vascular access
  • Aortic root dilation requiring surgical replacement
  • Unsuitable annulus size/shape
  • Problematic leaflet calcification
  • Insufficient coronary ostial height

Asymptomatic Severe AS with LVEF <50%

• Follow the same age-based algorithm as symptomatic patients. 1
• For asymptomatic patients with other high-risk features (abnormal exercise test, very severe AS, rapid progression, elevated BNP), SAVR is preferred over TAVI. 1

Critical Pitfalls to Avoid

• Do not use TAVI in patients <65 years with normal life expectancy despite increasing real-world practice patterns showing inappropriate expansion of TAVI to younger patients. 2, 5
• Do not proceed with either intervention if predicted survival is <12 months or minimal quality of life improvement expected; palliative care is recommended instead. 1
• Do not ignore the 4-fold higher permanent pacemaker requirement with TAVI (14.9% vs 3.4%), which may impact younger patients over their lifetime. 4
• Recognize that early mortality benefits with TAVI in lower-risk patients (at 1 year) disappear with longer follow-up, with no differences in death or stroke after 1 year. 3