TAVI or surgery for aortic stenosis:
how the choice is made

Article written and reviewed by Dr Luca Moretti

TAVI and surgical aortic valve replacement are both effective treatments for severe aortic stenosis, but they are not interchangeable in every patient. The choice depends on age, life expectancy, operative risk, valve and vascular anatomy, the presence of other heart diseases and the possibility of future interventions.
According to the 2025 ESC/EACTS guidelines, in Europe TAVI is recommended as the primary mode of intervention in patients aged at least 70 years with tricuspid aortic valve stenosis, suitable anatomy and feasible transfemoral access. In patients under 70 years of age at low surgical risk, surgery is preferred. All other cases require an individualized Heart Team decision.

This guide concerns the choice of procedure after an indication for valve replacement has been established. For diagnosis and severity, see the monograph on aortic stenosis.

What is the difference between TAVI and surgical replacement?

TAVI implants a bioprosthetic valve inside the diseased aortic valve using a catheter. In most cases, the preferred route is through the femoral artery. It does not require opening the chest with a sternotomy, and functional recovery is often faster than after conventional surgery.
SAVR, or surgical aortic valve replacement, is performed as cardiac surgery. It allows the diseased valve to be removed, a biological or mechanical prosthesis to be chosen when appropriate, and other conditions to be treated during the same operation, for example coronary artery disease requiring bypass surgery or dilatation of the ascending aorta.

TAVI is therefore not simply the “better option because it is less invasive,” and surgery is not automatically an outdated choice. They are different tools with different advantages and limitations.

Age: why in 2025 the European threshold fell to 70 years

Previous European guidelines used an age threshold of 75 years to guide the choice. The 2025 ESC/EACTS guidelines lowered it to 70 years because of accumulating randomized evidence in low-risk patients and medium-term outcomes with transcatheter prostheses.
For patients aged at least 70 years with a tricuspid aortic valve, suitable anatomy and feasible transfemoral access, TAVI is recommended. Below age 70, if surgical risk is low, surgery remains preferred because randomized data in younger patients are less extensive and prosthesis durability and the strategy for possible future procedures become central considerations.

Age is not used as an automatic switch, however. A 72-year-old person with anatomy unfavorable for TAVI may be an excellent surgical candidate; a younger person with high surgical risk or specific contraindications may require a different discussion. Frailty, comorbidities, life expectancy and patient preferences also matter.

When anatomy and other diseases favor surgery

Surgery is favored when TAVI cannot be performed safely by the transfemoral route or when anatomical features increase the risk of complications. These may include annular dimensions that are not compatible with available devices, particularly unfavorable calcification or a high risk of coronary obstruction.
The presence of a bicuspid aortic valve requires specific assessment. In younger patients, especially when dilatation of the ascending aorta is present, surgery allows the valve and aorta to be treated at the same time.

Complex coronary artery disease requiring bypass surgery, disease of another valve that needs surgical correction or a problem involving the ascending aorta can also shift the choice toward SAVR. Conversely, previous complex thoracic surgery, high operative risk or other conditions may make a transcatheter approach particularly advantageous.

Recovery, risks and valve durability: what really changes

With TAVI, in the absence of complications, mobilization and discharge are often faster because there is no need to wait for a sternotomy to heal. Surgery requires a longer recovery, but it offers the advantage of direct access that allows several cardiac problems to be addressed during the same operation.
The complication profiles differ. In modern randomized trials, TAVI has shown excellent results, but with some devices it may be more frequently associated with conduction disturbances and pacemaker implantation and with paravalvular regurgitation. Surgery is more invasive and may have a greater initial impact on bleeding, atrial rhythm, renal function and physical recovery, depending on the patient and the type of procedure.

Durability is particularly important in younger patients. Randomized data are now reassuring up to 7 years for PARTNER 3 and 10 years in the NOTION trial, but the populations studied have specific ages and characteristics. For a person who may live for several more decades, it remains necessary to plan what will happen when the first bioprosthesis deteriorates.
This concept of lifetime management includes the possibility of a future valve-in-valve procedure, coronary access after TAVI, prosthesis size and the feasibility of any reinterventions. It is one reason why the choice should not be reduced to a simple comparison between a shorter hospital stay and a more invasive operation.

Frequently asked questions about TAVI and surgery

Is TAVI always better after age 70?
No. The 2025 guidelines favor TAVI in patients aged at least 70 years with tricuspid aortic valve stenosis, suitable anatomy and feasible transfemoral access, but some anatomical or cardiac conditions make surgery preferable.

Can TAVI be performed in patients under 70?
It may be considered in selected situations, but in patients under 70 years of age at low operative risk, the European guidelines prefer surgery.

Is TAVI less risky than surgery?
There is no single answer that applies to everyone. The two approaches have different risk profiles, and the choice depends on individual characteristics.

Does a bicuspid valve change the choice?
Yes. Bicuspid anatomy, valve anatomy and aortic dimensions must be assessed particularly carefully, especially in younger patients.

How long does a TAVI valve last compared with a surgical valve?
Available data show good medium- and long-term durability in selected populations, but in very young patients life expectancy may exceed the duration currently documented by randomized trials. This is why a lifetime strategy is an integral part of the decision.