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D’Abramo et al. Vessel Plus 2019;3:4 I http://dx.doi.org/10.20517/2574-1209.2018.41 Page 5 of 7

transcatheter aortic valve replacement in low risk patients (NCT02701283), and NOTION 2 (NCT02825134)
[16]
[17]
trials . Tam et al. conducted a cost utility analysis comparing TAVI and SAVR in intermediate risk
patients with severe aortic stenosis and TAVI appeared to be also a cost - effective treatment not only in
[18]
terms of absolute value but also in terms of perspective quality of life and re-hospitalization. Villablanca et al.
published a meta-analysis on long-term outcomes of TAVR vs. SAVR. Their analysis confirms the findings
from RCTs about similar longterm mortality between SAVR and TAVR. TAVR showed higher incidence of
PPM implantation, residual aortic regurgitation, and vascular complications; SAVR showed higher incidence
of myocardial infarction. Incidence of stroke, atrial fibrillation and acute kidney injury were lower with
TAVR, especially in the high-risk population. Lastly the risk of PPM implantation is similar in intermediate-
risk patients between both TAVR and SAVR.

Data published on the comparison between RD-AVR and SAVR underline the benefits of RD-AVR in terms
of operative time reduction, CBP duration and increased effective orifice area and consequent lower post-
[19]
operative transvalvular gradient . The most common complications reported in the case of RD-AVR are
[20]
higher incidence of pacemaker implantation, postoperative stroke and residual aortic regurgitation , while
the most common complications reported in the case of standard procedure tend to be exclusively surgery
[21]
related as major bleeding or acute renal failure . Totally in contrast to these previous studies, the German
Aortic Valve Registry (GARY) recently analyzed a total of 22,062 patients who underwent isolated SAVR
[22]
using SAVR or RD-AVR between 2011 and 2015 . GARY analysis demonstrated that the advantages carried
by RD-AVR may not translate into effective benefits. Patients currently undergoing SAVR are at low -
intermediate surgical risk, with consequent low expected complication rates, so low pacemaker rate is still a
strong argument in favor of SAVR. According to the authors, there are no reasons for choosing RD-AVR and
increasing the risk of a post-operative PPM implantation. In contrast to the previous studies, this analysis
also showed significantly elevated post-operative transvalvular gradients in sutureless valves, independently
of the implanted valve sizes. At last, many data exist regarding comparison between RD-AVR and TAVI
even if they do not always stratify patients for surgical scoring risk, in consequence TAVI patients tend to
[23]
have higher scores. Meco et al. made a metanalysis of 6 studies including 1,462 patients (RD-AVR 731
vs. TAVI 731) with similar operative risk (Euroscore1: 15.45 ± 9 RD-AVR vs. 15.58 ± 8.1 TAVI). Thirty days
all cause mortality and complications as stroke, paravalvular regurgitation, vascular complications were
significantly lower in RD-AVR. The rate of acute kidney injury and pacemaker implantation were similar.
RD-AVR group required more transfusion. Mid term survival rates (at 1 or 2 years) were significantly better
in RD-AVR. SAVR using sutureless valves may be associated with better early and mid-term outcomes
compared with TAVI in high- or intermediate-risk patients; the authors found a 50% risk reduction in early
[24]
[23]
all causes of death and a 65% and 62% risk reduction in 1- and 2-year mortality for TAVI . Recently Shinn et al.
provided a meta analysis including 7 observational studies comprising 617 RD-AVR and 621 TAVI patients:
early mortality was 2.5% and 5% respectively, post procedural paravalvular leak was lower in RD-AVR and
post procedural stroke and need for pacemaker implantation were comparable between the two cohorts.

From several studies, it appears that post operative need for pacemaker implantation is similar in both
techniques, TAVI seems to have lower transvalvular gradients but more common peri-prosthetic leaks and,
[26]
[25]
in the end, RD-AVR seems to have lower mortality rates . Finally, a large study from D’onofrio et al.
obseverd 2,177 patients (1,885 TAVI vs. 292 RD-AVR): they found similar incidence of 30-day and 1 year
mortality rates, stroke, bleeding and myocardial infarction. Patients treated with TAVI showed less device
success and more postoperative perivalvular leak, even if this was less evident in trans apical procedures.
RD-AVR resulted in higher transaortic gradients, longer post operative length and similar pacemaker
[26]
implantation rate .

CONCLUSION
The Heart Team is nowadays tasked to determine the best option for each patient considering patient related
factors and cost effectiveness. The choice between surgical AVR vs. TAVR is based on multiple factors