TAVI vs SAVR: How Doctors Decide, and What TAVI Costs

The choice between TAVI and surgical aortic valve replacement (SAVR) rests on the patient's surgical risk, age and anatomy. Elderly, frail and high-risk patients, and those with good femoral arteries, favour TAVI; younger patients, bicuspid valves, low coronary arteries and coronary disease needing bypass favour surgery. A heart team should individualise the decision for each patient.

Dr. Subhash Chandra, Chairman - Interventional Cardiology - Cardiology & Structural Heart Disease, BLK-Max Super Speciality Hospital, New Delhi, India, performs a large volume of transcatheter aortic valve implantation (TAVI), also called transcatheter aortic valve replacement (TAVR). His position on the choice is nonetheless conservative: given a safe choice, surgery comes first. This article sets out how he and the guidelines weigh the two procedures, how the risk score works, what TAVI costs relative to surgery, and how referring doctors abroad can plan a case with his team. The disease itself, and when it needs treatment, is explained in the complete guide to TAVI for aortic stenosis; the procedure is described in how TAVI is planned and performed.

TAVI vs SAVR: the two procedures

Surgical aortic valve replacement opens the chest, places the patient on a heart-lung machine, removes the diseased valve and sutures a new one into the annulus, the ring of tissue at the base of the aorta in which the valve sits. Recovery involves a hospital stay of six to seven days in Dr. Chandra's account, and a longer convalescence after the sternotomy, the incision through the breastbone.

TAVI delivers a tissue valve on a catheter, usually through the groin, while the heart keeps beating, and the patient can stay awake. The implant itself takes about 20 to 30 minutes, and the patient avoids the chest incision and the heart-lung machine entirely.

Both are proven treatments for severe aortic stenosis. The question is which suits a given patient.

How surgical risk is measured: the STS-PROM score

The first step in the decision is a formal risk estimate. The STS-PROM (Society of Thoracic Surgeons Predicted Risk of Mortality) score is calculated by entering a patient's clinical parameters, such as age, kidney function, lung disease, heart function and previous surgery, into an online calculator that predicts the risk of death after surgery. Patients are conventionally graded as low risk (below 4%), intermediate risk (4 to 8%) or high risk (above 8%).

Once the patient has been graded, Dr. Chandra's team looks at further parameters: the presence of calcium that could lead to annular rupture, whether the iliofemoral arteries (the arteries running from the pelvis to the groin) offer good access, and the overall risk of TAVI against SAVR. Surgical risk is very high in the elderly, which is why TAVI has emerged as the default choice in that population.

Who should have surgery, and who should have TAVI

Dr. Chandra summarised the selection in two lists.

Factors that favour surgical aortic valve replacement:

• younger age
• a bicuspid aortic valve
• femoral access that is unfavourable for TAVI
• low coronary ostia, where the opening of a coronary artery could be blocked by a TAVI valve
• multivessel coronary artery disease that needs bypass grafting at the same operation as the valve replacement

Factors that favour TAVI:

• very advanced age
• a need for redo surgery, where opening the chest again is fraught with risk
• frailty
• high surgical risk
• good femoral access
• previous chest radiation, which makes reopening the chest hazardous
• a porcelain aorta, a heavily calcified aorta on which a surgeon cannot safely clamp or attach a graft

These lists mirror the factors set out in the European (ESC/EACTS) valvular heart disease guidelines, which recommend that the decision be made by a heart team of cardiologists and cardiac surgeons.

Is surgery or TAVI the safer default?

In Dr. Chandra's view, surgery remains the default whenever a patient can undergo it safely. Asked about the prognosis of SAVR compared with TAVI, he gave a clear personal position. SAVR has been established for more than 50 years and, given a choice, should in his opinion be the default in terms of safety. Although he performs a great deal of TAVI, he prefers a technique that is well proven and well established, especially when the valve is bicuspid, the annulus is small or the patient is not very elderly.

His working rule is collaborative. If his surgeon accepts the patient and can operate safely, the patient goes for surgery. If the surgeon judges the surgical risk to be very high, Dr. Chandra steps in and takes the patient for TAVI. Many surgeons, he added, are now learning TAVI themselves, because they know the problems they encounter when operating on high-risk patients.

He acknowledged the evidence on the other side. Recent trials have shown TAVI to be non-inferior to surgery even in intermediate- and low-risk patients, with both self-expanding and balloon-expandable valves. The large low-risk trials, PARTNER 3 and Evolut Low Risk, were reported in 2019. Even so, his conclusion is that the decision should be individualised to the patient.

What the guidelines say about age

Guidelines use age as a practical proxy for how long a valve must last:

• The 2025 ESC/EACTS guideline recommends TAVI for patients aged 70 or older with a three-leaflet valve and suitable anatomy, or those at high surgical risk or unsuitable for surgery, and SAVR for patients under 70 at low surgical risk. The previous 2021 edition set this threshold at 75.
• The 2020 ACC/AHA guideline favours SAVR for patients under 65, TAVI for those over 80, and a shared decision between patient and heart team for those aged 65 to 80.

Valve durability is the reason. A TAVI valve is expected to last at least 10 to 15 years, in Dr. Chandra's estimate, and the field is working to extend that beyond 15. A younger patient will outlive more than one valve, so the long track record of surgery carries more weight.

TAVI cost in India compared with open heart surgery

In Dr. Chandra's account, TAVI in India costs about double open heart surgery, while in the West it can cost less, and he explained why the comparison runs in opposite directions.

In India, open heart surgery is cheaper than in the West, because hospital care, the bed and everything else across a six- to seven-day stay cost far less. Minimally invasive devices, on the other hand, carry the cost of the innovation that goes into them, so minimally invasive procedures cost slightly more than, or at best the same as, the surgical alternative.

In the West the equation reverses. Hospital overheads and surgical procedures are much more expensive, so TAVI can cost even less than surgery.

The headline figure for an international patient is his: TAVI can be offered in India for as little as 25,000 US dollars. Device choice also matters: the Indian-made Myval balloon-expandable valve comes, by his estimate, at almost 50% of the price of the SAPIEN valve. For the surgical alternative, see the cost of aortic valve replacement in India.

Referring a patient for TAVI from abroad

Referring doctors abroad can send a locally performed CT scan and the case details to Dr. Chandra's team, who plan the procedure before the patient travels; a typical stay is three or four days, and a week at most. For Ethiopia and neighbouring countries such as Kenya and Tanzania, Dr. Chandra's view is that local teams are energetic in learning but services for these procedures are still evolving. By his estimate, close to 60% of these cases would qualify as complex, and those patients are best served by travelling to a country such as India, where treatment is most cost-effective.

The logistics, as he described them, are manageable:

• Travel. Direct flights take about six hours. A patient comes for a week at most, often only three or four days, has the procedure and flies home.
• Planning before travel. The CT scan that drives every TAVI decision can be done locally and sent to his team, who plan the valve and anticipate coronary, groin and stroke risks before the patient arrives.
• Online advice. His hospital answers almost 20 queries a day from different countries in Africa. If a doctor sends details, the team responds with a viable solution. Many problems can be solved locally. Where a case is too complex, the team finds a way to bring the patient to Delhi and treat them in the most cost-effective manner, which is simpler still when the patient has insurance cover.

Building local capacity

Referral is only part of his approach. Dr. Chandra has visited Ethiopia several times over the past ten years, by his account helped establish cardiac programmes there, and has trained doctors from the country through exchange. He described two routes for doctors:

• Fellowship. Any interventional cardiologist with a basic grounding in the field can apply by sending a CV, followed by an interview in person or online. Fellows spend about a year on coronary angioplasty, then a second year in the structural heart programme, learning TAVI, left atrial appendage occlusion, TMVR and other structural interventions. Two fellows from Ethiopia were completing two years with him at the time of the masterclass.
• Proctoring exchange. He travels to a country for five days to a week, the local team lines up a range of cases, and either he performs them or the local operators do so with him behind them as proctor. Cases that cannot be done locally are referred to Delhi.

The details of the fellowship and exchange programme, and doctors' other questions, are in the Live Discussion from this masterclass. Surgical alternatives through smaller incisions are covered in a separate series on minimally invasive aortic and mitral valve surgery, and other heart conditions in the cardiology specialty hub.