TAVR (Transcatheter Aortic Valve Replacement) — Procedure Guide, Recovery & Risks | MyMedicPlus

Transcatheter aortic valve replacement (TAVR), also called TAVI (transcatheter aortic valve implantation), is a minimally invasive procedure to replace a diseased aortic valve by threading a collapsible bioprosthetic valve through a catheter — usually via the femoral artery in the groin — without opening the chest. It was developed as an alternative to open surgical aortic valve replacement (SAVR) for high and intermediate surgical risk patients, and is now approved for low-risk patients at many centres. TAVR requires a multidisciplinary Heart Team including interventional cardiologists and cardiac surgeons for case selection and procedure planning with cardiac CT.

Two main valve platforms are available: the balloon-expandable Edwards SAPIEN 3 Ultra (deployed by inflating a balloon to expand the valve frame into position) and the self-expanding Medtronic Evolut PRO+ (which deploys gradually, allowing repositioning before full release). Both achieve excellent haemodynamic performance with valve areas greater than 1.5 cm² and mean gradients less than 15 mmHg. Procedural success rates exceed 98% at experienced TAVR centres. Over 100,000 TAVR procedures are performed annually in the United States alone, with global volumes exceeding 400,000 per year.

TAVR is indicated for severe symptomatic aortic stenosis causing angina, syncope, or heart failure in patients deemed high or intermediate surgical risk by a Heart Team comprising a cardiologist and cardiac surgeon. Based on landmark PARTNER and CoreValve trials, TAVR is now also approved for low-risk patients at experienced centres. The procedure is also used for failed surgical bioprosthetic valves (valve-in-valve TAVR). Anatomical suitability is assessed by cardiac CT to measure aortic annulus size, iliofemoral vessel calibre, and coronary ostia height before proceeding.

Heart Team assessment considers: STS-PROM score (Society of Thoracic Surgeons Predicted Risk of Mortality), EuroSCORE II, frailty index (Clinical Frailty Scale, grip strength, 5-metre walk test), anatomical suitability (CT assessment of aortic annulus dimensions, iliofemoral vessel calibre for transfemoral access, coronary artery height, ascending aortic dimensions), and patient preferences regarding recovery, scar, and valve durability. TAVR is now approved for low-risk patients in most major jurisdictions, expanding eligibility to younger patients who previously would have undergone surgery.

After Heart Team assessment and cardiac CT planning, the patient undergoes TAVR in a hybrid catheterisation laboratory. Under anaesthesia or conscious sedation, a catheter is inserted through the femoral artery and advanced under fluoroscopy and transoesophageal echocardiography guidance across the narrowed aortic valve. The balloon-expandable (Edwards SAPIEN) or self-expanding (Medtronic Evolut) bioprosthetic valve is positioned at the aortic annulus and deployed within the native diseased valve, pushing it aside and immediately restoring normal blood flow. The catheter is removed and the groin access site closed with a vascular closure device. The procedure typically takes 2-3 hours.

Transfemoral TAVR is now performed in the majority (greater than 90%) of cases via a 14–16 French sheath in the femoral artery. The native aortic valve is pre-dilated with a balloon, then the transcatheter heart valve (THV) is advanced on a delivery catheter and positioned within the native aortic annulus under fluoroscopic, echocardiographic, and angiographic guidance. Final valve position is confirmed by angiography and echocardiography. Paravalvular leak (PVL) assessment using colour Doppler is performed before sheath removal. Vascular closure is achieved with percutaneous suture devices (ProGlide, MANTA). Newer iteration techniques including 'cusp overlap' fluoroscopic projection and commissural alignment optimise valve deployment for coronary re-access in future procedures.

TAVR has revolutionised treatment of severe aortic stenosis. In the PARTNER 3 and Evolut Low Risk trials, TAVR was non-inferior and in some measures superior to SAVR in low-risk patients. At 2 years, TAVR patients had lower rates of stroke, hospitalisation, and mortality in combined endpoints.

The PARTNER 1A trial established TAVR superiority over medical management in high-risk patients (50.7% vs 44.1% survival at 3 years). The PARTNER 2 trial showed equivalence with surgery in intermediate-risk patients. Quality of life improvements after TAVR are rapid and dramatic — the majority of patients report resolution of angina, dyspnoea, and syncope within 30 days, with sustained improvements in 6-minute walk distance and KCCQ (Kansas City Cardiomyopathy Questionnaire) scores. The procedure transforms valve function immediately: mean aortic valve gradient falls from greater than 40 mmHg to less than 10 mmHg, enabling the left ventricle to eject against a dramatically reduced pressure load. Symptoms resolve rapidly: dyspnoea, syncope, and angina from aortic stenosis improve in over 90% of patients within 30 days.

TAVR complications include stroke (2-4%), vascular access site complications requiring repair (3-5%), permanent pacemaker requirement (10-15% for self-expanding valves due to conduction system compression), paravalvular aortic regurgitation (mild residual leak in 20-30%), and acute kidney injury (5%). Procedural mortality at experienced centres is 1-3% for high-risk patients and below 1% for low-risk patients. Valve durability data shows structural valve deterioration at 5-10 years in some patients, but valve-in-valve TAVR allows non-surgical re-intervention when needed.

Permanent pacemaker implantation is required in 10–15% of self-expanding valve patients and 3–5% of balloon-expandable valve patients, due to conduction system compression from the lower landing zone of the valve frame. Paravalvular leak (PVL) — incomplete sealing of the valve against the aortic annulus — occurs in mild degree in 20–30% and moderate-to-severe in 3–5%, associated with increased mortality when significant. Coronary obstruction (rare, less than 1%) is a potentially catastrophic complication managed by coronary wire protection or BASILICA leaflet laceration technique.

Most TAVR patients are ambulatory within hours of the procedure and discharged home within 2-3 days. Temporary pacemaker leads placed during the procedure may be required permanently in 10-15% of patients who develop complete heart block. Antiplatelet therapy (dual antiplatelet for 3-6 months, then lifelong aspirin) is prescribed at most centres; anticoagulation alone may suffice for patients with concurrent atrial fibrillation. Echocardiography at 30 days, 1 year, and annually monitors valve function and gradient. A cardiac rehabilitation programme is recommended to optimise functional recovery and exercise capacity within 4-8 weeks.

Antiplatelet therapy post-TAVR: dual antiplatelet therapy (DAPT) with aspirin and clopidogrel for 3–6 months, transitioning to single antiplatelet (aspirin) lifelong, unless the patient has another indication for anticoagulation (AF — anticoagulation alone, no antiplatelet). Patients undergo echocardiography at 1 month, 12 months, and then every 3–5 years to monitor valve haemodynamics and detect structural valve deterioration. TAVR valve durability data at 5–8 years demonstrate maintained haemodynamic function in over 90% of cases, addressing earlier concerns about transcatheter valve longevity.