Treating aortic stenosis: TAVI, surgery, and choosing a prosthesis

TAVI or conventional surgery: understanding the two options

Both techniques have the same goal: to replace the failing aortic valve with a prosthesis. They differ in their access route, anesthesia requirements, and the patient profile for which they are intended.

Conventional surgery (surgical aortic valve replacement) involves opening the chest via sternotomy, temporarily stopping the heart, and replacing the valve while on cardiopulmonary bypass. It allows for the implantation of both types of prostheses (mechanical and biological) and the simultaneous treatment of any potential coronary artery disease. The hospital stay is typically around one week to ten days.

TAVI (transcatheter aortic valve implantation) involves introducing a collapsed biological prosthesis via a catheter, usually through the femoral artery in the groin. The valve is deployed without opening the chest, under light sedation or general anesthesia, with a shorter hospital stay. This technique was performed for the first time in the world at the Rouen University Hospital in 2002 by Professor Alain Cribier—a breakthrough that transformed the care of patients at high surgical risk.

The criteria that guide the choice between one technique or the other include:

• Age and frailty : TAVI is preferred for older or frailer patients, for whom the risks of open surgery are higher. ‍
• Cardiac and vascular anatomy : a pre-TAVI CT scan is used to verify that the access routes and cardiac structures are compatible with the percutaneous procedure. ‍
• Patient preferences : particularly regarding the type of prosthesis and the constraints associated with each option.

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Mechanical or biological prosthesis: the importance of a personalized choice

Choosing the type of prosthesis is a secondary decision-making issue, distinct from the choice of surgical technique. It involves a long-term commitment for the patient and deserves to be discussed in detail with the medical team.

• The mechanical prosthesis is made of durable materials. It requires lifelong anticoagulant treatment (usually with vitamin K antagonists) to prevent blood clots from forming on the valve. It is generally intended for younger patients, for whom avoiding long-term reoperation is an advantage. ‍
• The bioprosthesis is made from biological tissues (porcine or bovine). In the vast majority of cases, it does not require lifelong anticoagulants, which simplifies daily life, especially for patients with contraindications to anticoagulants. It may require reoperation eventually, depending on how the prosthesis evolves in each patient.

The criteria taken into account for this choice include age, the presence of contraindications to anticoagulants, lifestyle habits, and patient preferences. This is a shared decision between the patient and their medical team, not a standardized choice.

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The MDT meeting: a collective decision built around your case

The multidisciplinary team (MDT) meeting brings together the various specialists involved in your care to review your case: cardiologists specializing in valvular heart disease, cardiac surgeons, anesthesiologists, and, depending on the situation, geriatricians or doctors from other specialties.

During this meeting, several factors are reviewed: echocardiography and CT scan results, patient comorbidities, valvular and vascular anatomy, surgical risk levels estimated by validated scores, and patient preferences. Following this consultation, a recommendation is made for TAVI, surgery, or continued monitoring in asymptomatic cases.

This structure ensures that the decision is not based on the opinion of a single physician, but on a collective, multidisciplinary review of the case. It is currently the standard recommended by European scientific societies for all patients with severe aortic stenosis.

Post-procedure follow-up is also managed by this team, including regular control echocardiograms, monitoring of anticoagulants for patients with mechanical prostheses, and prevention of infective endocarditis—a rare but important complication for anyone with a prosthetic valve to be aware of.