For patients with severe symptomatic aortic stenosis, surgical aortic valve replacement (SAVR) is the reference treatment where surgical risk is low. For those assessed by a heart team as being at increased surgical risk transcatheter aortic valve implantation (TAVI) is an alternative procedure. SAVR can be performed using different surgical approaches (full sternotomy and more minimally invasive procedures), different kinds of valves, and different kinds of valve anchoring techniques (sutured and sutureless). TAVI involves the insertion of a prosthetic valve, which functionally replaces the damaged aortic valve, using fluoroscopic and echographically guided minimally invasive procedures. The prosthetic valve is compressed within a dedicated delivery system and, once in place within the diseased aortic valve, its deployment allows its expansion and the compression of
the native diseased valve against the wall of the aorta. Depending on the anatomy of the patient and device characteristics, the procedure can be performed by one of four different approaches. The transfemoral (TF) route is the most common, whereas the others are performed when the anatomy of the patient precludes access via the TF route. These approaches are the subclavian/ transaxillary (S/T) approach, the transapical (TA) approach, and the transaortic (TAo) approach. Evidence note | 6 Data from randomised controlled trials (RCTs) in elderly patients at who are at high surgical risk indicate that TAVI is non-inferior or superior to SAVR2. This is reflected in SHTG advice on the use of TAVI in patients who are inoperable or at high surgical risk3, 4. This evidence review examines the evidence comparing outcomes of TAVI and SAVR in patients with severe aortic stenosis who are at intermediate surgical risk.