TAVR vs SAVR for severe aortic stenosis
Clinical Question
In adults with asymptomatic severe aortic stenosis and low surgical risk, should
transcatheter aortic-valve replacement (TAVR) or surgical aortic-valve replacement
(SAVR) be recommended as the preferred initial strategy?
Background
Management of severe aortic stenosis has evolved rapidly over the past decade,
driven largely by the expansion of transcatheter aortic-valve replacement into lower-
risk and younger patient populations. While symptoms have traditionally been the
primary trigger for intervention, increasing evidence suggests that select
asymptomatic patients, particularly those with impaired left ventricular systolic
function, may benefit from earlier valve replacement.
For patients at low surgical risk, both TAVR and SAVR are guideline-supported
options, yet uncertainty remains regarding long-term durability, stroke risk, valve
thrombosis, and lifetime management strategies. This uncertainty is especially
relevant in asymptomatic patients, where the threshold to intervene is already
nuanced and the choice of modality may have long-term consequences.
Design
A Clinical Decisions article published in the New England Journal of Medicine
addresses this dilemma. As with other articles in this series, the format centres on a
real-world clinical vignette followed by two opposing expert viewpoints. These pieces
are not randomized trials, but rather structured debates that integrate contemporary
evidence, guideline recommendations, and expert interpretation to inform decision-
making in areas of ongoing clinical uncertainty
The case describes a 72-year-old woman referred for evaluation of severe aortic
stenosis after a murmur is detected on routine examination. Transthoracic
echocardiography confirms severe high-gradient aortic stenosis, with a mean
gradient of 42 mm Hg, an aortic valve area of 0.9 cm², and a left ventricular ejection
fraction of 44%. Despite these findings, she reports no exertional symptoms and
maintains an active lifestyle. She has well-controlled hypertension, no diabetes or
lung disease, and is deemed to be at low surgical risk based on STS-PROM and
EuroSCORE II scores. With an indication for valve replacement driven by impaired
left ventricular systolic function rather than symptoms, the treating team must decide
whether to recommend TAVR or SAVR.
Outcome
Two expert perspectives are presented. One argues in favour of TAVR, emphasising
its less invasive nature, faster recovery, and evidence from contemporary trials
demonstrating noninferiority to surgery in low-risk patients. The argument highlights
the importance of patient preference, shared decision-making, and the relevance of
emerging data, including sex-specific evidence, supporting TAVR in appropriately
selected patients.
The opposing viewpoint supports SAVR, focusing on long-term durability, concerns
about late stroke and valve thrombosis, and the absence of robust data beyond 10
years for TAVR in low-risk populations. This perspective stresses the concept of lifetime valve management and argues that surgery may better preserve future
treatment options in patients with longer life expectancy
Strengths
A key strength of the Clinical Decisions format is its ability to frame complex,
preference-sensitive decisions in a balanced and accessible way. By presenting
competing expert interpretations of the same evidence, the article mirrors real-world
heart team discussions and highlights where data are robust versus where
uncertainty persists.
The interactive component further enhances engagement, allowing readers to vote
on nejm.org and compare their clinical instincts with those of peers and experts once
the poll results are published.
The Bottom Line
This Clinical Decisions article captures a central question in the management of
asymptomatic severe aortic stenosis at low surgical risk: while TAVR offers clear
short-term advantages and growing evidence of efficacy, SAVR remains the
benchmark for long-term durability and lifetime planning.
In the absence of definitive long-term comparative data in asymptomatic, low-risk
patients, the choice between TAVR and SAVR should be individualized.
Multidisciplinary heart team assessment, anatomical considerations, anticipated
longevity, and patient values are critical to informed decision-making. As the
evidence base continues to mature, particularly with longer-term follow-up from low-
risk trials, this debate is likely to remain highly relevant to everyday practice.
External Links
Transcatheter or Surgical Aortic-Valve Replacement in Asymptomatic Severe Aortic Stenosis
Metadata
Summary author: Chris Kotanidis @cpkotanidis
