Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Valve Replacement on Clinical Outcomes in Patients with Aortic Stenosis

Cordeiro, André Luiz Lisboa; Gonçalves, Emmanuel de Souza; Santana, Rute Macêdo de; Santos, Tayane Siqueira Martins dos

doi:10.36660/abc.20240295

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Review Article • Arq. Bras. Cardiol. 122 (10) • Oct 2025 • https://doi.org/10.36660/abc.20240295i linkcopy

Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Valve Replacement on Clinical Outcomes in Patients with Aortic Stenosis

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Aortic stenosis (AS) is one of the most prevalent valve lesions, and transcatheter aortic valve replacement (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR). TAVI is a minimally invasive procedure that has proven to be a safer option in several aspects. The objective is to review the impact of TAVI compared to surgical aortic valve replacement on mortality, postoperative complications, hospitalization, and quality of life in patients with AS. A systematic review was conducted using the PICO strategy, with searches in the PubMed, Central, and LILACS databases, employing the following descriptors: aortic stenosis, hospitalization, mortality, clinical trial, transcatheter aortic valve implantation, quality of life, postoperative complications, combined with the Boolean operators “AND” and “OR.” A total of 29 articles were found after reading the titles and abstracts. Of these, nine showed lower mortality in patients undergoing TAVI, while three reported lower mortality in the SAVR group. Eight articles had similar findings regarding complications, with six showing a lower incidence of postoperative complications in TAVI and three in SAVR. Additionally, three articles showed better quality of life in TAVI patients, while one study indicated a shorter hospital stay for TAVI patients. In all studies, the patients analyzed were over 70 years old. TAVI reduced mortality compared to SAVR in patients with AS. Furthermore, TAVI was associated with a reduction in hospital stay and improvement in quality of life. Regarding postoperative complications, the results indicated that TAVI tends to have a lower complication rate, although variations exist between studies.

Keywords:
Aortic Valve Stenosis; Transcatheter Aortic Valve Replacement

Central Illustration:
Transcatheter Aortic Valve Implantation (TAVI) Versus Surgical Valve Replacement on Clinical Outcomes in Patients with Aortic Stenosis

Study (Author/year)	Country	Sample	Design	Inclusion criteria	Interventions			Measurements	Results
Study (Author/year)	Country	Sample	Design	Inclusion criteria	Intervention	Control		Measurements	Results
	USA	742 TAVI (n = 389) SAVR (n = 353)	Randomized clinical trial	Patients with severe aortic stenosis and heart failure symptoms of the New York Heart Association (NYHA) class II	TAVI	SAVR conventional open-heart techniques with the use of cardiopulmonary bypass.	Mortality		Mortality At 1 year: 14.2% in the TAVI group 19.1% in the SAVR group Absolute reduction in risk of 4.9 percentage points (confidence interval, −0.4; P<0.001 for noninferiority; P = 0.04 for superiority).
Adams et al. 2014¹⁰	USA	742 TAVI (n = 389) SAVR (n = 353)	Randomized clinical trial		TAVI		Mortality
Søndergaard et al. 2016¹¹	Denmark and Sweden	276 TAVI (n = 142) SAVR (n = 134)	Randomized clinical trial	Severe native aortic valve stenosis	TF-TAVI	SAVR	Mortality		Mortality At 2 years 8.0% in the TAVI group 9.8% in the SAVR group p=0.54.
Skelding et al. 2016¹²	USA	353 TAVI (n = 183) SAVR (n = 170)	Randomized clinical trial	Female patients with New York Heart Association (NYHA) class II or greater symptoms and severe aortic stenosis	TAVI	SAVR conventional surgery	Mortality and Postoperative Complications		Mortality at 30 days All-cause mortality 3.8% in the TAVI group 4.7% in the SAVR group p = 0.70 Stroke: 5.6% in the TAVI group 6.5% in the SAVR group p = 0.73 Myocardial infarction: 1.6% in the TAVI group 0.6% in the SAVR group p = 0.35 Major vascular complications 7.7% in the TAVI group 0.6% in the SAVR group p = 0.001 Cardiac perforation 2.7% in the TAVI group 0.0% in the SAVR group p = 0.03 Permanent pacemaker implantation 20.7% in the TAVI group 7.2% in the SAVR group p < 0.001
Grayburn et al. 2018¹³	USA	739 TAVI (n = 386) SAVR (n = 353)	Randomized clinical trial	Patients were stratified by the severity of baseline AR (aortic regurgitation) into those with none and/or trace and those with mild AR	TAVI	SAVR	Mortality		Mortality 49% (84 of 172 patients) in the TAVI group 8% (13 of 162 patients) in the SAVR group
Conte et al. 2017¹⁴	USA	790 TAVI (n = 391) SARV (n = 359)	Randomized clinical trial	Severe aortic stenosis	TAVI iliofemoral or non-iliofemoral access ports	SAVR	Postoperative Complications, mortality		Mortality at 2 years 8.0% in the TAVI group 9.8% in the SAVR group p = 0.54 Major Vascular Complications: Significantly higher in the TAVI group during the periprocedural period (5.4% vs. 1.4%, p = 0.003)
Leon et al. 2021¹⁵	USA	950 TAVI (n = 496) Surgery (n = 454)	Randomized clinical trial	Patients with severe aortic stenosis	TAVI transfemoral	Minimally invasive surgery	Mortality		Mortality at 2 years TAVI: 57 patients (11.5%) SAVR: 78 patients (17.4%) p = 0.007
Durko et al. 2018¹⁶	Europe, USA, Canada	1660 TAVI (n = 864) Surgery (n = 796)	Randomized controlled trials	Patients with severe, symptomatic aortic stenosis at intermediate surgical risk	TAVI	SAVR conventional surgery	Complications		Early strokes: TAVI: 3.3% SAVR: 5.4% p = 0.031 Early encephalopathy: TAVI: 1.6% SAVR: 7.8% p < 0.001
Thyregod et al. 2013¹⁷	Scandinavia	280 TAVI (n = 140) SAVR (n = 140)	Randomized clinical trial	Patients 70 years or older with severe degenerative AV stenosis with symptoms or without symptoms but with left ventricular systolic dysfunction and/or hypertrophy	TAVI	SAVR complete median sternotomy	Complications or all-cause mortality (primary outcome)		Myocardial infarction, stroke, or all-cause mortality. SAVR group: 15% incidence TAVI group: 5% incidence p<0.001
Gleason et al. 2016¹⁸	USA	750 TAVI (n = 391) SAVR (n = 359)	Randomized clinical trial	High-risk patients (predicted SAVR mortality 15%) with severe aortic stenosis	TAVI	SAVR	Mortality and complications		30-day stroke rate: TAVI: 4.9% SAVR: 6.2% p = 0.46 1-year stroke rate: TAVI: 8.7% SAVR: 12.5% p = 0.11 2-year stroke rate: TAVI: 10.9% SAVR: 16.6% p = 0.05 2-year all-cause mortality: TAVI: 83.3% SAVR: 54.5% p = 0.29
Kapadia et al. 2018¹⁹	USA	5637 TAVI (n = 4389) SAVR (n = 1248)	Randomized clinical trial	Patients with aortic stenosis	TF-TAVI	SAVR	Complications and quality of life		30-day Stroke: TF-TAVI: 5.1% SAVR: 3.7% p = 0.09 30-day Major Stroke: TF-TAVI: 3.9% SAVR: 2.2% p = 0.018 SAVR (KCCQ score): Without major stroke: 79 [53, 94] With major stroke: 64 [30, 94] p = 0.03 TF-TAVI (KCCQ score): Without major stroke: 78 [49, 96] With major stroke: 60 [8, 99] p = 0.04
Mack et al. 2015²⁰	USA	699 TAVI (n = 348) SAVR (n = 351)	Randomized controlled trial	Patients with severe aortic stenosis	TF-TAVI	SAVR type of surgery not specified	Mortality		Mortality At 5 years 67.8% in the TAVI group 62.4% in the SAVR group p=0.76.
Deeb et al. 2016²¹	USA	750 TAVI (n = 391) SAVR (n = 359)	Randomized clinical trial	Patients with severe aortic stenosis	TAVI	SAVR procedure at the discretion of the cardiac surgeon	Mortality and complications		Three-year outcomes All-cause mortality or stroke 37.3% in the TAVI group 46.7% in the SAVR group p=0.006 All-cause mortality 32.9% in the TAVI group 39.1% in the SAVR group p=0.068 All stroke 12.6% in the TAVI group 19.0% in the SAVR group p=0.034 Major adverse cardiovascular or cerebrovascular events 40.2% in the TAVI group 47.9% in the SAVR group p=0.025
Kapadia et al. 2015²²	USA	358 TAVI (n = 179) SAVR (n = 179)	Randomized clinical trial	Patients with severe symptomatic inoperable aortic stenosis (mean age 83 years, Society of Thoracic Surgeons Predicted Risk of Mortality 11·7%, 54% female).	TF-TAVI	Balloon aortic valvuloplasty	Mortality		Five-year outcomes All-cause mortality 71.8% in the TAVI group 93.6% in the SAVR group p<0.0001
Thyregod et al. 2015²³	Denmark and Sweden	274 TAVI (n = 139) SAVR (n = 135)	Randomized clinical trial	Patients ≥70 years of age with severe degenerative aortic valve stenosis	TF-TAVI	SAVR underwent conventional open heart surgery with the use of cardiopulmonary bypass	Mortality and complications		One-year outcomes Death from any cause, stroke, or MI (primary outcome) 13.1% in the TAVI group 16.3% in the SAVR group −3.2% absolute difference; p=0.43 for superiority
Gleason et al. 2018²⁴	USA	750 TAVI (n = 391) SAVR (n = 359)	Randomized clinical trial	Patients with severe, symptomatic (New York Heart Association [NYHA] functional class II or greater) aortic stenosis	TAVI	SAVR	Mortality and complications		Five-year outcomes All-cause mortality 55.3% in the TAVI group 55.4% in the SAVR group Major stroke 12.3% in the TAVI group 13.2% in the SAVR group
Toff et al. 2022²⁵	UK	866 TAVI (n = 450) SAVR (n = 416)	Randomized clinical trial	Patients were aged 70 years or older with severe, symptomatic aortic stenosis and increased operative risk due to comorbidity or age.	TAVI	SAVR (midline sternotomy and minimally invasive surgery	Mortality		One-year outcomes All-cause mortality 4.6% in the TAVI group 6.6% in the surgery group Adjusted absolute risk difference −2.0% (1-sided 97.5% CI, −∞ to 1.2%)
Généreux et al. 2014²⁶	USA	657 SARV (n = 313) TAVI-TF (n = 240) TARV-TA (n = 104)	Randomized clinical trial	Patients with severe symptomatic aortic stenosis	TF-TAVI OR TA-TAVI	SAVR	Postoperative Complication		30-day outcomes Major BC (blood complications) 22.7% after SAVR 11.3% after TF-TAVI 8.8% after TA-TAVI p<0.0001 30-day transfusion rate 17.9% after SAVR 7.1% after TF-TAVI 4.8% after TA-TAVI p<0.0001
Amrane et al. 2019²⁷	Canada, Europe, USA	936 SARV (n = 438) TAVI (n = 498)	Randomized clinical trial	Patients with severe symptomatic AS are considered to be of intermediate surgical risk.	TF-TAVI	SAVR	Mortality		One-year outcomes All-cause mortality 6.5% after TAVI 6.7% after SAVR
Leon et al. 2016²⁸	USA	2032 TAVI (n = 1011) SAVR (n = 1021)	Randomized clinical trial	Intermediate-risk patients with severe aortic stenosis	TF-TAVI OR TA-TAVI	SAVR transthoracic or transaortic access	Postoperative Complications and Mortality		Death from any cause or a disabling stroke Overall: Similar rates between TAVI and surgery p=0.001 for noninferiority
Reardon et al. 2011²⁹	USA, Canada, Europe	1657 TAVI (n = 863) SAVR (n = 794)	Randomized clinical trial	Intermediate-risk patients with severe symptomatic aortic stenosis	TF-TAVI	SAVR	Postoperative Complications, life quality, and mortality		24-month outcomes All-cause mortality 11.4% in the TAVI group 11.6% in the surgery group 95% confidence interval for difference, −3.8% to 3.3% Disabling stroke Similar rates in both groups Quality of life (KCCQ summary score) Significant improvement in both groups over 24 months A greater proportion of patients improved at 1 month in the TAVI group compared to the surgery group
Smith et al. 2011³⁰	EUA, Canada, Germany	699 SARV (n = 351) TAVI-TF (n = 244) TARV-TA (n = 104)	Randomized clinical trial	Patients with severe aortic stenosis and cardiac symptoms (New York Heart Association [NYHA] class II function or worse)	TF-TAVI OR TA-TAVI	SAVR conventional surgery	Postoperative Complications and mortality		30-day and 1-year outcomes All-cause death 30 days: 3.4% in transcatheter group vs. 6.5% in surgical group (p=0.07) 1 year: 24.2% in transcatheter group vs. 26.8% in surgical group (p=0.44) Reduction of 2.6 percentage points in the transcatheter group Upper limit of 95% CI for difference: 3.0 percentage points Predefined margin: 7.5 percentage points; p=0.001 for noninferiority Major stroke 30 days: 3.8% in transcatheter group vs. 2.1% in surgical group (p=0.20) 1 year: 5.1% in transcatheter group vs. 2.4% in surgical group (p=0.07) Major vascular complications 30 days: 11.0% in transcatheter group vs. 3.2% in surgical group (p<0.001)
Makkar et al. 2020³¹	USA	2032 TARV- TF (n = 1550) SAVR (n = 482)	Randomized clinical trial	Intermediate-risk patients with severe symptomatic aortic stenosis	TF-TAVI	SAVR in the transthoracic region	Mortality, Postoperative Complications, Quality Of Life		Five-year outcomes All-cause mortality 4 7.9% in the TAVI group 43.4% in the surgery group p=0.21 At least mild paravalvular aortic regurgitation 33.3% in the TAVI group 6.3% in the surgery group Health status improvement Similar improvement in both TAVI and surgery groups at 5 years
Kapadia et al. 2014³²	USA	449 TAVI (n = 220) SAVR (n = 229)	Randomized clinical trial	Inoperable patients with severe aortic stenosis	TAVI TF	SAVR TF	Mortality		Three-year mortality 54.1% in the TAVI group 80.9% in the SAVR group p<0.001
Baron et al. 2019³³	USA	943 TAVI (n = 494) SAVR (n = 449)	Randomized clinical trial	Patients with severe aortic stenosis (AS) of low surgical risk	Transfemoral TAVI using a balloon-expandable valve	SAVR	Quality of life		At 1 month TAVI showed better health status than SAVR Mean difference in KCCQ-OS: 16.0 points, p<0.001 At 6 months TAVI remained better than SAVR, though with a reduced effect Mean difference in KCCQ-OS: 2.6 points, p<0.04 At 12 months TAVI still showed better health status, with a further reduced effect Mean difference in KCCQ-OS: 1.8 points, p<0.04 Proportion of patients with KCCQ-OS ≥75 and no significant decline from baseline At 6 months: 90.3% in TAVI vs. 85.3% in SAVR, p=0.03 At 12 months: 87.3% in TAVI vs. 82.8% in SAVR, p=0.07
Garcia et al. 2021³⁴	USA	1524 TAVI (n = 1045) SAVR (n = 479)	Randomized clinical trial	Patients with severe aortic stenosis (AS) and chronic kidney disease (CKD) undergoing TAVI or SAVR	TAVI	SAVR	Complication		Perioperative Acute Kidney Injury (AKI) 26.3% after SAVR 10.3% after TAVI p<0.001
Vandermolen et al. 2021³⁵	USA	322 TAVI (n = 220) SAVR (n = 102)	Randomized clinical trial	Patients with classic low-flow, low-gradient aortic stenosis	TAVI	SAVR	Mortality		Median follow-up of 2.7 years (range 1.5–4.1 years) 99 patients had died: 70 (31.8%) in the TAVI group 29 (28.4%) in the SAVR group
Forrest et al. 2022³⁶	USA	1414 TAVI (n = 730) SAVR (n = 684)	Randomized clinical trial	Patients with aortic stenosis in low-risk patients	TAVI	SAVR	Mortality and complications		All-cause mortality rates 3.5% in the TAVI group 4.4% in the SAVR group p=0.366 Disabling stroke rates 1.5% in the TAVI group 2.7% in the SAVR group , p=0.119
Kapadia et al. 2015²³	USA	358 TAVI (n = 179) SAVR (n = 179)	Randomized clinical trial	Patients with severe inoperable aortic stenosis	TAVI	SAVR	Mortality		Five-year outcomes All-cause mortality 71.8% in the TAVI group 93.6% in the SAVR group p<0.0001
Forrest et al. 2023³⁷	USA	1414 TAVI (n = 730) SAVR (n = 684)	Randomized clinical trial	Low-Risk Patients with Aortic Stenosis	TAVI with self-expanding supraannular valve	SAVR	Mortality and complications		Mortality rates (all-cause or disabling stroke) Year 1: −1.8% difference (TAVI vs. Surgery) Year 2: −2.0% difference Year 3: −2.9% difference Incidence of mild paravalvular regurgitation 20.3% in the TAVI group 2.5% in the surgery group Pacemaker placement 23.2% in the TAVI group 9.1% in surgery group p<0.001 Moderate or greater paravalvular regurgitation <1% in both groups No significant difference

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[TFN1001] TF-TAVI: transfemoral aortic valve transcatheter implantation; SAVR: surgical aortic valve replacement; AR: aortic regurgitation; NYHA: New York Heart Association Functional Classification; TA-TAVI: transfemoral aortic valve transcatheter implantation; LDB: life-threatening or disabling hemorrhage; AKI: acute kidney injury; AV: aortic valve; KCCQ: Kansas City Cardiomyopathy Questionnaire; KCCQ-OS: Kansas City Cardiomyopathy Questionnaire Overall Summary Score; HR: Hazard Ratio; CI: confidence interval; USA: United States of America; UK: United Kingdom; AS: aortic stenosis.