When is the right time for TAVR? Understanding your heart valve options
February 10, 2025
Your aortic valve controls blood flow from the heart to the rest of your body. Aortic stenosis, a progressive disease, can occur when that valve becomes narrower and reduces blood flow. It can cause severe symptoms, such as chest pain, shortness of breath, and extreme fatigue. If left untreated, it can eventually lead to heart failure.
For decades, open-heart surgery to replace the aortic valve was the only treatment for aortic stenosis. For some patients, surgical aortic valve replacement, known as SAVR, is still the recommended therapy.
In 2011, the U.S. Food and Drug Administration approved transcatheter aortic valve replacement (TAVR), a game-changing minimally invasive procedure for patients who were too sick for open-heart surgery. TAVR replaces the valve through a catheter inserted in the femoral artery in the groin rather than by opening the chest and going on cardiopulmonary bypass.
Today, TAVR is an option for most patients with severe aortic stenosis symptoms and valve narrowing, not just the very sick. About 100,000 are done in the U.S. each year. As of November 2024, UT Southwestern has performed over 1,000 TAVR procedures.
Current valve replacement guidelines from the American Heart Association and the American College of Cardiology recommend that patients with severe aortic stenosis and no symptoms get checked by their doctor every 6-12 months. Once symptoms begin, patients can choose either SAVR or TAVR, based on their age, heart function, and discussion with their doctor.
However, the EARLY TAVR study published in October 2024 in The New England Journal of Medicine suggests that getting TAVR sooner – before symptoms begin – can reduce the risk of hospitalization, stroke, or death after a median of 3.8 years of follow-up. Though more data are needed to shift the AHA/ACC guidelines, the idea of further expanding the benefits of TAVR is exciting.
So, when is the right time to get an aortic valve replacement procedure? And when is TAVR the best choice? The answers vary depending on each patient’s specific needs and circumstances.
Who should consider aortic valve replacement?
Symptoms
-Chest pain
-Fatigue
-Shortness of breath and coughing
-Heart palpitations
-Dizziness or fainting with activity
-Lower extremity swelling
The decision to get any type of valve replacement due to aortic stenosis starts with a discussion about the severity of symptoms and how much the valve has narrowed.
Usually when there is severe narrowing due to aortic stenosis, patients have symptoms, which is the trigger to consider a valve replacement procedure. Symptoms may be mild to severe.
Aortic stenosis causes the aortic valve to stiffen, which builds pressure in the lower left chamber of the heart. Over time, aortic stenosis reduces the heart’s ability to pump oxygenated blood through the body and can lead to heart failure, blood clots, stroke, and pulmonary hypertension (high blood pressure in the arteries of the lungs).
Patients who do not have symptoms may not need valve replacement right away. Some may choose guideline-directed medical therapy, which is a combination of medications to treat and prevent heart failure. These patients should see their cardiologist regularly for imaging to look for changes in the aortic valve and discuss any new symptoms that arise.
Severe narrowing may trigger symptoms
Based on the patient’s symptoms, age, overall health, and the stage of their aortic stenosis, we can determine whether valve replacement is recommended and which type to consider.
Aortic stenosis is staged by valve function and severity of symptoms:
- Stage A: No current valve dysfunction, but the patient is at risk of developing it in the future due to a congenital valve abnormality, such as a bicuspid valve, where the aortic valve has only two cusps, or flaps, instead of three. These patients will be clinically surveilled, which means they’ll get regular follow-up echocardiograms, and no immediate action is needed.
- Stage B: Mild to moderate aortic stenosis with no symptoms. These patients would be clinically surveilled and may start medication.
- Stage C: Severe aortic stenosis on an echocardiogram, but still no symptoms and no functional declines. A stress test (exercise on a treadmill) and blood tests to check for cardiovascular strain help guide the decision to get either TAVR or SAVR along with medication.
- Stage D: Severe aortic stenosis that causes symptoms and affects the patient’s daily functioning. Patients need valve replacement and medication to survive.
The EARLY TAVR study followed 901 patients with Stage C aortic stenosis in 75 centers across the U.S. and Canada for one year. Researchers put patients, with an average age of 76, through stress testing to ensure they were truly asymptomatic. The patients were then randomized to either get a transcatheter heart valve or to have clinical surveillance, which involves monitoring from their doctor for disease progress and symptom development.
Data showed that patients who got TAVR in Stage C had lower rates of unexpected hospitalization, strokes, and death than those in the surveillance group after less than 4 years of follow-up. Five-year survival rates are a typical milestone for treatment guidelines.
Researchers will continue to follow these patients through March 2032. We are curious to find out whether longer-term data will continue to show benefits from early intervention in this patient population.
Is TAVR the best option for me?
TAVR is less invasive than open-heart surgery. However, that does not mean it is the best choice for every patient. Before we recommend a type of valve replacement, we talk through several criteria with patients.
How long will the new valve last?
The bioprosthetic material used in TAVR valves is similar to what’s used in SAVR. However, TAVR is still relatively new. In contrast, decades of data exist on the long-term durability of replacement valves in SAVR. I expect that long-term data, when available, will show that the durability of TAVR valves is similar.
For now, we consider a patient’s age to estimate how long they’ll live with their valve as part of our recommendation for TAVR or SAVR:
- Younger than 50: SAVR with a mechanical valve is typically recommended for this age group. These devices are built to last a lifetime, but patients must take blood thinner medications for life to reduce the risk of blood clots.
- Age 51-65: SAVR is still the recommended treatment for this age group due to the robust data available on the durability of SAVR valves.
- Age 65-80: Patients can choose between SAVR and TAVR, based on their overall health.
- Older than 80: We typically recommend TAVR because it is minimally invasive with an easier recovery period.
Do you have other cardiovascular conditions?
Patients with significant blockages due to coronary artery disease may benefit from SAVR. In some scenarios, a heart stent procedure can also be considered along with TAVR. That way, the surgeon can potentially perform one procedure to address the blockage and replace the valve, reducing the need for multiple surgeries.
Patients with structural differences in their aorta may not be a good candidate for TAVR. Though rare, leakage around the replacement valve can occur with TAVR because the valve is not sutured in place.
About 10%-15% of patients who get TAVR will need a permanent pacemaker, which is slightly higher than the risk with SAVR.
Related reading: TAVR is not the ‘beginning of the end’ for aortic stenosis open heart surgery
What should I expect if I get TAVR?
TAVR is a minimally invasive procedure that does not require opening the chest or stopping the heart. It's typically done while the patient is under sedation. An interventional cardiologist inserts a thin tube called a catheter, affixed with a deflated surgical balloon, into the femoral artery through a small incision in the groin.
With the help of imaging, the doctor guides the catheter containing the new valve to the heart. The doctor then inflates a balloon to widen the narrowed artery and positions the replacement valve inside the damaged one. It is not sutured in place because the original valve is able to hold it in place.
Patients are typically sitting up within hours of a TAVR procedure, and most go home from the hospital within two days. There are some risks involved with any procedure. For TAVR, the risks are low and may include bleeding where the catheter was inserted, damage to the heart, or leaking around the replacement valve. Risks of TAVR for most patients are comparable to or lower than risks associated with open-heart surgery.
TAVR was introduced as an option for people with aortic stenosis who would not be a candidate for open-heart surgery. Today, TAVR is a standard of care for many patients who meet criteria, regardless of surgical risk.
As research continues, we expect to see more patients become eligible for TAVR earlier in the disease process. If we can slow or stop aortic stenosis before symptoms begin, there is potential to significantly improve patients’ quality of life and give them more high-quality years with their families.
To talk with an expert about aortic stenosis treatment options, call 214-645-8000 or request an appointment online.
