TAVR Versus Open Heart Valve Surgery: Which Is Right for You?

From the authors of The Cardiac Surgery Playbook: Daniel T. Engelman, MD, Cheryl Crisafi, MSN, RN, and Armando Paez, MD

For a narrowed aortic valve, there are now two ways to replace it. Open surgery, called SAVR, has more than 60 years of results behind it. TAVR, the catheter approach, avoids opening the chest. Because TAVR is less invasive, it is easy to assume it must be the better choice. For many people it is an excellent option. But the choice is truly two-sided, and it deserves a balanced discussion.

What each procedure involves

In SAVR, surgical aortic valve replacement, the surgeon removes the diseased valve and sews a new one in place. This is usually done through the breastbone, and in some centers through a smaller incision. The heart-lung machine supports your circulation. Its big advantage is that the surgeon can fix several problems at once, such as blocked arteries, another valve, or an enlarged aorta.

In TAVR, transcatheter aortic valve replacement (sometimes written TAVI), a replacement valve is folded down small and guided to the heart through a thin tube, most often from an artery in the groin. It is opened inside the old valve. There is no breastbone cut. The hospital stay is often only a day or two, and early recovery is usually quicker.

Who tends to be offered which

Large trials published between 2010 and 2019 extended TAVR from high-risk patients to those at medium and then low surgical risk. For many people with the right anatomy, either approach can be reasonable.

TAVR is often favored when open surgery would be riskier: older age, frailty, a past heart operation, a chest that would be difficult or dangerous to reopen, a heavily calcified aorta, or serious lung disease.

SAVR is often favored when other problems must be fixed at the same time, such as blocked arteries, a second bad valve, or an enlarged aorta. It also fits some bicuspid valves, very small valve openings, active valve infection, and whenever a long-lasting mechanical valve is the goal.

How they compare in the trials

In the large trials comparing the two in lower-risk patients, survival and stroke rates were similar at five years. The differences lie in the trade-offs at the time of the procedure and in what is known about the long term.

TAVR generally means no chest cut, a shorter hospital stay, a quicker early recovery, less bleeding, and less new atrial fibrillation. Surgery carries a lower chance of needing a pacemaker and a lower chance of a leak around the valve. It also offers the ability to fix other problems in the same operation, the option of a mechanical valve, and decades of data on how long surgical valves last.

These comparisons come mainly from the five-year results of the two main low-risk trials, PARTNER 3 and Evolut Low Risk. In both, TAVR's early advantage faded over time, and results differ by valve type and by center. Your own numbers depend on your valve, your anatomy, and where you are treated.

The pacemaker question

The heart's main electrical pathway runs right beneath the aortic valve. A TAVR valve is held in place by the outward force of its frame, which presses on this pathway. As a result, a permanent pacemaker is needed more often after TAVR than after surgery.

After surgical replacement, about one in twenty people needs a pacemaker. After TAVR it is about one in nine on average, but the valve type matters: roughly one in fifteen with a balloon-expandable valve and about one in six with a self-expanding valve. Newer designs keep lowering this risk, so ask your team for the figures that apply to your valve.

Age, and how long valves last

A replacement aortic valve, whether placed by surgery or catheter, is usually a tissue valve, and tissue valves wear out. They wear out faster in younger patients and more slowly in older ones. In older people a tissue valve often lasts the rest of their lives. In people in their fifties, the same valve may need attention within a couple of decades, or sooner.

Mechanical valves, available only through surgery, are the most durable and rarely need replacing. They require lifelong warfarin. Guidelines lean toward mechanical valves for younger patients and tissue valves for older patients. Between about ages fifty and sixty-five, either is reasonable.

So the real question is not only how you will feel next month. It is how many valve procedures you may need over the rest of your life, and what each one will involve. For a frail person over eighty, a valve that lasts ten years may last a lifetime. For a fit sixty-year-old, the first valve is the opening move in a longer sequence.

What happens when the valve wears out

This is the point most likely to tip a younger, healthier patient toward surgery, and the one patients are least likely to hear discussed.

When a surgical tissue valve wears out, a new valve can usually be placed inside it by catheter. This is called a valve-in-valve procedure, and most patients tolerate it well.

When a TAVR valve wears out, a second TAVR inside the first is sometimes possible, but not always. The existing metal frame can block later access to the heart's own arteries. When a repeat catheter procedure is not safe, the failed TAVR valve must be removed by surgery, an operation called an explant. It is more complex than a standard valve replacement, and it is among the fastest-growing heart operations in the United States.

TAVR is now routinely offered to people in their fifties and sixties, ahead of long-term data on how long it lasts in that age group. The point is not that TAVR is a poor procedure. For the right patient, it is the right one. The point is that the trade-offs of a catheter-first strategy should be weighed out loud.

Questions for your Heart Team

For most aortic valve decisions, the standard of care is a review by a Heart Team that includes both a cardiac surgeon and an interventional cardiologist. If only one option has been presented to you, it is reasonable to ask about the other.

• Am I a candidate for both TAVR and surgery? Does this center offer both?
• Why is one recommended over the other in my case?
• How long is this valve likely to last at my age, and what is the plan when it wears out?
• What is my chance of needing a pacemaker with each option?
• Do I have other problems, such as blocked arteries, that could be fixed in the same operation?
• Would a mechanical valve make sense for me?

Learn more in The Cardiac Surgery Playbook

Chapter 4, Valve Surgery, includes the full SAVR-versus-TAVR comparison, a table of surgery-first and TAVR-first strategies, and the valve choices for the mitral and tricuspid valves. Our page on heart valve surgery covers repair versus replacement and tissue versus mechanical valves.

Go deeper in the book. Chapter 4: Valve Surgery; Chapter 11: What to Ask Your Surgeon and Team. Written by a cardiac surgeon, a cardiac surgery nurse and an infectious disease physician, with worksheets you can fill in for your own care.

Paperback Hardcover Kindle

This page is general education, not medical advice. Your own surgeon and care team know your situation best. If you think you are having a medical emergency, call 911.

More questions before heart surgery