Transcatheter Aortic Valve Replacement (TAVR)

Few innovations in cardiovascular medicine have transformed patient care as dramatically as transcatheter aortic valve replacement (TAVR). What began as a treatment reserved for patients too sick to undergo surgery has evolved into a mainstream therapy for severe aortic stenosis, offering many patients shorter recovery times, less pain, and excellent outcomes.

However, as recently discussed in The Wall Street Journal, TAVR is not a simple procedure: long-term success depends heavily on patient selection, procedural expertise, and thoughtful lifetime valve management.

As TAVR technology continues to advance and indications expand into younger and lower-risk populations, the conversation in cardiology is evolving. The question is no longer simply whether TAVR can be performed safely. In experienced hands, it clearly can. The more nuanced questions are these: which patients are best served by TAVR, which are better served by surgical valve replacement (SAVR), and how do we optimize outcomes not just for the next year, but for the next 10 to 20 years or more?

That distinction matters enormously.

For many patients, TAVR is truly life changing. We routinely see elderly or frail patients who would once have faced prolonged recovery after open-heart surgery walking the halls the next day and returning home within 24 to 48 hours. Prior to TAVR, many of these patients would have been deemed too risky for surgery and would have succumbed to their aortic stenosis.

At the same time, it is important not to oversimplify what remains a highly sophisticated structural heart intervention. Aortic valve disease is not “one size fits all” and neither are replacement strategies.

One of the most important issues receiving increased attention nationally is valve durability. Bioprosthetic valves—whether surgically implanted or delivered by catheter—do not last forever. Younger patients, by definition, place more years of stress on a valve prosthesis, and managing a patient’s “lifetime valve strategy” has become one of the central challenges in modern structural heart medicine.

This is where experience matters.

Not all transcatheter valves perform identically over time, and not all patients are anatomically suited for every valve type. Factors such as annular size, coronary anatomy, calcium burden, vascular access, future coronary access considerations, risk of conduction abnormalities, and long-term valve durability all influence procedural planning. Even subtle technical decisions made during pre-procedural evaluation can significantly affect outcomes years later.

In some cases, a patient may strongly prefer a minimally invasive procedure yet still be better served by surgical valve replacement. That can be a difficult conversation, particularly when patients understandably focus on avoiding open-heart surgery. But part of delivering excellent structural heart care is having the experience and discipline to recommend the right therapy rather than simply the newest or least invasive therapy.

For younger and lower-risk patients especially, surgical valve replacement often remains an outstanding option. Modern surgical outcomes are excellent, particularly in high-quality centers, and surgery may provide superior long-term durability for selected patients. In some individuals, surgery may also preserve future treatment options more effectively over the course of a lifetime.

Conversely, there are many patients for whom TAVR is unquestionably the optimal approach. The challenge—and the art—lies in determining which path is best for each individual patient.

That decision-making process requires far more than procedural skill alone. Successful TAVR programs depend on comprehensive multidisciplinary structural heart teams that include interventional cardiologists, cardiac surgeons, advanced imaging specialists, anesthesiologists, heart failure physicians, electrophysiologists, nursing coordinators, and experienced advanced practice providers working together in a coordinated fashion.

Volume and experience also matter. Numerous studies across cardiovascular medicine have demonstrated that higher-volume centers generally achieve better outcomes in complex procedures. TAVR is no exception. Programs that perform these procedures frequently develop the institutional expertise necessary to manage difficult anatomy, recognize subtle procedural risks, minimize complications, and navigate challenging clinical scenarios when they arise.

Importantly, expertise is not measured solely by procedural success rates on the day of implantation. True structural heart excellence includes careful screening, appropriate patient selection, longitudinal follow-up, management of valve durability issues, and the ability to address complications or reinterventions should they become necessary years later.

As structural heart medicine continues to evolve, we should resist the temptation to frame TAVR and surgical valve replacement as competing therapies. They are complementary tools. The goal should never be to maximize procedural numbers. The goal should be to deliver the right therapy to the right patient at the right time, using evidence, experience, and sound clinical judgment. This is no small issue; as stated by one cardiac surgeon, “recent national data show that among patients under 65 with isolated aortic stenosis, more than half of bioprosthetic aortic valve replacements were performed with TAVR, and nearly half of the lowest-risk patients received TAVR. Similar patients had strikingly different odds of undergoing TAVR depending on the hospital where they were treated.” (H. Wang, M.D., Ph.D. Wall Street Journal, May 14).

At Bryan Heart, we are proud of the structural heart program we have built. Our program at Bryan Medical Center in Lincoln performs more TAVR procedures annually than any other center in Nebraska, and that experience has allowed us to develop a highly collaborative, patient-centered approach to complex valve disease. The work performed locally in Lincoln has not gone unnoticed as Bryan Medical Center became American College of Cardiology (ACC) Transcatheter Valve Certified in 2025.  We remain committed not only to procedural excellence, but also to careful patient selection, thoughtful long-term planning, and continuous quality improvement. As technology advances and treatment options continue to expand, our focus remains unchanged: delivering the safest, most durable, and most appropriate care possible for every patient entrusted to us.

For more information, please contact our office at 402-483-3333.