Great debate: surgical aortic valve replacement is first choice for aortic stenosis in patients with a life expectancy beyond 5 years

Transcatheter aortic valve implantation (TAVI) is increasingly used for the treatment of aortic stenosis. Recently published guidelines favour now TAVI in all patients 70 years or older who have tricuspid valves and suitable anatomy. However, while a number of randomized controlled trials confirm that TAVI and surgical aortic valve replacement (SAVR) provide equivalent outcomes up to 5 years, data beyond 5 years are still scarce and real-world registry data report indeed conflicting results. Higher rates of complications after TAVI such as pacemaker requirement and paravalvular regurgitation, which have been shown to be associated with worse outcome may become more relevant after 5 years and still favour surgery on long-term. In addition, long-term durability data for TAVI are still insufficient. Thus, the question whether SAVR should still be the first choice for patients with a life expectance beyond 5 years is therefore justified. This debate summarizes the pros and cons for this claim.