TAVR vs. Redo Open Heart Surgery for Aortic Valve Stenosis: How to Choose the Right One for You

“If someone has already had their aortic valve replaced and they've now developed dysfunction of that prosthetic valve, we often have to make a decision between TAVR and redo [open heart] surgery,” says Mackram F. Eleid, MD, an interventional cardiologist with Mayo Clinic.

Whether transcatheter aortic valve replacement (TAVR) or redo surgical aortic valve replacement (SAVR, an open heart surgery) is right for you is an important decision you have to make with your care team. These two treatment paths carry their own risks and benefits that should be carefully weighed.

What Are TAVR and SAVR?

The redo SAVR procedure is more invasive and involves the surgical team opening your chest. “They take the old valve out, whether that's an old surgical valve or old transcatheter valve, and put a new one in,” says Gilbert Hin-Lung Tang, MD, the surgical director of the Structural Heart Program at the Mount Sinai Health System in New York City. “About a third of the time, the surgeon needs to do additional procedures to either repair or replace another valve, or do coronary bypass or other reconstructive work.”

With TAVR, often called a valve-in-valve procedure, the surgeon will leave the old failing valve in place. Rather than open the chest, they will create a pinkie-size cut in your groin to access a major artery, Dr. Tang says. They’ll then thread a long, flexible tube called a catheter to your aortic valve and use the device to deploy a new valve directly inside the old valve.

Weighing the Clinical Risks

Choosing between TAVR and redo SAVR ultimately comes down to weighing the procedures’ various risks and benefits, many of which shift depending on factors like your age, health, and how long you’ll need the replacement valve.

Survival Rates

Research comparing these two procedures is limited, making it challenging to draw concrete conclusions or collect survival statistics.

Patients who undergo redo SAVR are typically the lower-risk patients who don't have any prior open-heart surgery or other major illnesses, Dr. Eleid says.

Complication Risks

There are some notable similarities and differences between TAVR and SAVR when it comes to risk of complications.

Recovery

One of the biggest benefits of TAVR over SAVR is recovery time.

“For [open] surgery, the first 24 hours are typically in the intensive care unit, depending on how complex the surgery is,” Tang says. “For TAVR, most patients, unless there's a complication, go straight to the regularly monitored floor and get discharged once they're medically ready.”

This also means that people who undergo TAVR are able to get up and move around a lot sooner. They usually have to rest in bed for several hours to allow the artery in the leg to heal, Eleid says. “Patients are usually walking in the afternoon or evening that same day,” he notes.

Pacemakers

Both TAVR and SAVR carry risks for needing a permanent pacemaker implantation.

“When we're fixing the aortic valve with any technique, we can injure the wiring of the heart because the conduction system, the electrical system of our heart, runs right by the aortic valve,” Eleid says.

Valve Longevity

It’s important to consider how long your replacement valve will last, especially if you’re a younger patient who may have it for years to come.

“Surgical valves last quite some time, especially the current generation, which tends to last 10 or more years,” Tang says. “For TAVR, we now have up to 7-year data that looks very good … but beyond that we're not sure yet.”

How to Choose the Right Procedure for You

• Older patients typically get TAVR because of the risks of open heart surgery.
• Greater frailty increases risks associated with surgery.
• Life expectancy: Surgical valves may last longer, which is a consideration if you have greater life expectancy.
• Other health conditions: People with conditions such as coronary artery disease may need to be treated simultaneously through open heart surgery.
• You’ll need open heart surgery if the valve size does not fit your body.
• Initial replacement procedure: Scar tissue from open heart surgery can make redo surgery especially risky.
• Tolerance for anticoagulation medications. Blood thinners may be needed if you develop blood clots from TAVR-related paravalvular leakage.