TAVI (Transcatheter Aortic Valve Implantation)
Dr Dawkins performs this procedure at Cleveland Clinic London and at the John Radcliffe Hospital in Oxford, where he is Clinical Lead for Structural Intervention.
TAVI stands for transcatheter aortic valve implantation and is a technique to replace a narrowed aortic valve. It is also known as transcatheter aortic valve replacement (TAVR). It is a minimally invasive procedure to replace the aortic valve without the need for open-heart surgery, usually via one of the arteries in the groin.
I have been referred for TAVI, what are the next steps?
TAVI requires careful assessment and planning to ensure the treatment is the right option for you, and that the procedure is carried out as safely as possible. The process begins with a consultation to discuss your symptoms and review any investigations that have been done so far. The diagnosis of severe aortic stenosis (a severely narrowed valve) is usually made using a transthoracic echocardiogram, but occasionally other tests are needed. We plan the procedure with a CT scan which will usually be carried out soon after your initial consultation.
How do I know if TAVI is the best option for me?
Once we have completed all the necessary investigations, we will discuss your case in detail at a meeting of experts in the management of aortic valve disease (the TAVI multidisciplinary meeting, MDT). This meeting is attended by cardiologists, cardiac surgeons, anaesthetists, radiologists, physicians and nurses with the aim of selecting the right patients for the procedure and carefully planning each step of the procedure to minimise risk. There are generally three options to consider: for many patients, TAVI will be a safe and effective option; for some others, conventional open-heart surgery may be the better option; and in rare cases the risks of any procedure may be prohibitive and we may recommend management with drug therapy only, though it is important to note that no medication alters the progression or prognosis of aortic stenosis.
Complex TAVI
Not every aortic valve is straightforward, and Dr Dawkins treats the full range of complex aortic valve anatomy, including:
- Bicuspid aortic valves, where the valve has two leaflets instead of three.
- Very small or very large valves, and heavily calcified aortic roots.
- High risk of coronary obstruction, where the coronary arteries arise low down or close to the valve and a new valve could block them. Careful CT planning identifies these patients in advance, and specialist techniques such as BASILICA and UNICORN can be used to keep the coronary arteries clear.
- Failing previous valves: TAVI inside a previous surgical valve (TAV-in-SAV) or inside a previous TAVI (TAV-in-TAV).
- Difficult vascular access, where narrowed or calcified arteries would normally rule out the groin approach. Techniques such as peripheral angioplasty and intravascular lithotripsy can often make a transfemoral approach possible.
Patients who have been told elsewhere that TAVI is not possible are very welcome to ask for a second opinion, and Dr Dawkins frequently treats patients who have been turned down at another centre.
For patients with a leaking (rather than narrowed) aortic valve, see TAVI for aortic regurgitation.
What are the benefits and risks?
The aim of aortic valve replacement, whether by TAVI or surgery, is to relieve symptoms and improve quality of life. TAVI has been shown to offer similar outcomes when compared to surgical aortic valve replacement and a quicker recovery in most patient groups. Some patients notice an improvement in their breathing immediately, and others notice an improvement over the subsequent weeks as they get back to normal activity. The TAVI procedure is not without risk and it is important that you and your family understand these risks. We will give you an idea of the likely risks during your consultation, and once we have the TAVI CT we can give you a more detailed assessment of the risks specific to you. You will have a chance to ask questions about the risks and benefits of the procedure, and information on your procedural risk will be provided both face to face and in writing for you to read after your consultation.
What can I expect from the TAVI procedure?
The TAVI procedure is usually carried out under sedation, but occasionally under general anaesthetic, which will be discussed in advance. Usually we use one of the femoral arteries in the groin to deliver the TAVI valve. The TAVI valve is made of cow or pig heart tissue mounted on a metal stent frame, which is expanded over the existing aortic valve. The procedure takes around an hour. Most patients stay in hospital for one night, although some need an extra day for monitoring.
What experience does Dr Dawkins have in aortic stenosis and TAVI?
Dr Dawkins trained in TAVI at Cedars-Sinai Medical Center in Los Angeles, one of the busiest valve centres in the world. He chairs the Oxford TAVI multidisciplinary meeting and personally reviews the planning CT for every patient he treats, and he runs a twice-yearly course teaching clinicians from around the world how to analyse TAVI CT scans. He teaches complex TAVI techniques internationally, including approaches for patients with difficult vascular access, and is an implanter of both the JenaValve and the J-Valve, dedicated devices for aortic regurgitation.
TAVI or open-heart surgery?How the choice of aortic valve treatment is made
Two ways to replace the aortic valve
A narrowed aortic valve can be replaced in two ways: with TAVI, through the artery at the top of the leg, or with surgical aortic valve replacement, an open-heart operation. Both are well established. The choice is made together with you, after discussion at a meeting of cardiologists, cardiac surgeons, imaging specialists and anaesthetists.
What do the guidelines say?
The 2025 European guidelines recommend [1]:
- TAVI for people aged 70 or over with a normal three-leaflet aortic valve, if the anatomy is suitable.
- TAVI for people aged 75 or over, at high risk from surgery, or unable to have surgery.
- Surgery for people under 70 at low risk from surgery.
- Either, for everyone else, depending on their heart and general health.
For a bicuspid valve, which has two leaflets instead of three, the guidelines are more cautious. TAVI may be considered for people at increased risk from surgery, if the anatomy is suitable [1].
What can favour surgery?
- Another heart problem that needs an operation at the same time: for example, another valve that needs treating, complex narrowings of the coronary arteries that need bypass surgery, or an enlarged aorta.
- Valve anatomy that suits surgery better: for example, a bicuspid valve, very heavy calcium at the base of the valve, a valve outside the range of TAVI sizes, or a risk of blocking the arteries that supply the heart muscle.
What can favour TAVI?
- Suitable arteries in the legs, so the valve can be delivered through the groin.
- Things that make an operation riskier: for example, frailty, other medical conditions, previous bypass surgery with grafts that are still working, a heavily calcified aorta, previous radiotherapy to the chest, or a severe chest deformity or curvature of the spine.
What is recovery like?
- TAVI: most patients go home the same day or after one or two nights. There is no wound on the chest, and many people notice an improvement in their breathing straight away or over the following weeks.
- Surgery: the operation is usually carried out through the breastbone, which needs time to heal, so the stay in hospital and the recovery afterwards are longer. Most patients stay in hospital for between five and seven days. Some patients may be suitable for minimally invasive aortic valve replacement, where the surgeon uses a smaller incision, either through the upper part of the breastbone or between the ribs on the right side of the chest, which leaves a smaller scar. Whether this is possible depends on your anatomy, and is decided with the cardiac surgeon.
The PARTNER 3 trial compared TAVI with surgery in 1,000 patients at low risk from surgery, with an average age of 73 [2]:
- Hospital stay: the typical stay was 3 days after TAVI and 7 days after surgery (P<0.001).
- Symptoms and walking distance: these improved sooner after TAVI. By one year, the difference between the two groups had narrowed.
- Irregular heart rhythm: new atrial fibrillation developed in the first month in 5.0% of TAVI patients, compared with 39.5% after surgery (P<0.001).
Thinking ahead
Tissue valves, whether surgical or TAVI, can wear out over time, so younger patients may need another procedure later in life. The guidelines ask the heart team to plan the first procedure with this in mind [1]. A worn surgical valve can often be treated with a TAVI valve placed inside it, and a worn TAVI valve with a second TAVI, but each of these has its own risks, and removing a TAVI valve surgically carries more risk than a first operation. Dr Dawkins will talk through how this applies to you.
References
- Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal 2025;46:4635–4736. doi:10.1093/eurheartj/ehaf194
- Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients. New England Journal of Medicine 2019;380:1695–1705. doi:10.1056/NEJMoa1814052
The evidence: key studiesPublished trial and registry results, with references
These summaries describe the main published studies of TAVI and how it developed. The figures are the results reported in those studies, not predictions for any individual patient. Where a study reports a P value, it is included. A P value shows how likely a difference of that size would be to arise by chance if the two treatments were really equal. A value below 0.05 is usually taken to mean the difference is unlikely to be due to chance ("statistically significant"). Dr Dawkins is happy to go through these results with you.
How long has TAVI been around?
The first TAVI procedures in the UK were carried out around 20 years ago. TAVI is now the most common way of replacing the aortic valve. In 2024/25 more than 10,000 TAVI procedures were performed in the UK, 97% of them through the artery in the groin [1]. Over the same year, about 3,800 aortic valve replacements were carried out by open-heart surgery, and about 1,700 more combined with coronary bypass surgery: about 5,500 surgical operations in all [2].
How was TAVI shown to work?
TAVI was tested in a series of randomised trials, each in patients at lower risk than the one before. How risky surgery would be is usually estimated with a score (the STS score), which predicts the chance of dying within 30 days of open-heart surgery. Most of these trials were part of the PARTNER programme, using the SAPIEN balloon-expandable valve.
- PARTNER 1B (2010): 358 patients who were too unwell for open-heart surgery received either TAVI or the best available treatment without a new valve. At one year, 30.7% of the TAVI patients had died, compared with 50.7% of those who did not have a new valve (P<0.001) [3]. This was an early generation of the valve and the procedure was new. In the first month, strokes (5.0% compared with 1.1%, P=0.06) and major injuries to the blood vessels (16.2% compared with 1.1%, P<0.001) were more common after TAVI than they are today.
- PARTNER 1A (2011): 699 patients at high surgical risk (an estimated risk of dying from surgery of 10% or more) received either TAVI or open-heart surgery. Survival at one year was the same: 24.2% died after TAVI and 26.8% after surgery. The trial showed TAVI was no worse than surgery (P=0.001) [4]. TAVI was now a real alternative to surgery, not only an option for those who couldn’t have an operation.
- PARTNER 2 (2016): 2,032 patients at intermediate risk (an estimated risk of dying from surgery of roughly 4 to 8%) were treated with a smaller, second-generation valve (SAPIEN XT). Death or disabling stroke at two years was similar: 19.3% after TAVI and 21.1% after surgery, so TAVI was no worse (P=0.001). In patients treated through the groin, results with TAVI were slightly better (P=0.05) [5].
- PARTNER 3 (2019): 1,000 patients at low surgical risk (an estimated risk of dying from surgery of under 4%; the average was 1.9%), average age 73, were treated with the current SAPIEN 3 valve. One year after the procedure, fewer TAVI patients had died, had a stroke or been readmitted to hospital: 8.5%, compared with 15.1% after surgery (P=0.001) [6].
Independently of the PARTNER programme, a large trial in Germany (DEDICATE) of 1,414 patients aged 65 or over found fewer deaths or strokes in the first year after TAVI than after surgery: 5.4% compared with 10.0%, so TAVI was no worse (P<0.001) [7].
What happened in the first month in PARTNER 3?
PARTNER 3 is probably the trial closest to most of Dr Dawkins’s patients. The trial published P values for some of its 30-day results. For the others it published a confidence interval, which shows whether the difference was statistically significant. In the first 30 days [6]:
- Death: 0.4% after TAVI, compared with 1.1% after surgery. Not statistically significant.
- Stroke: 0.6%, compared with 2.4%. Statistically significant (P=0.02).
- Serious bleeding: 3.6%, compared with 24.5%. Statistically significant.
- Kidney injury, of any severity: 1.4%, compared with 8.6%. Statistically significant.
- New atrial fibrillation (an irregular heart rhythm): 5.0%, compared with 39.5%. Statistically significant (P<0.001).
- Major blood-vessel complications: 2.2%, compared with 1.5%. Not statistically significant.
- New pacemaker: 6.5%, compared with 4.0%. Not statistically significant.
The typical hospital stay was 3 days after TAVI and 7 days after surgery (P<0.001). 96% of TAVI patients went straight home, compared with 73% after surgery.
What are the results like in the UK?
Every TAVI in the UK is recorded in a national audit. For planned (elective) procedures in 2024/25 [1]:
- Death within 30 days: about 1.1%.
- Stroke in hospital: about 1.4%.
- Major complications at the blood vessel in the groin: fewer than 1 in 100 patients.
All three have fallen steadily over the past decade. Results are less good when TAVI has to be done urgently, in patients who are already very unwell. This is one reason not to put off treatment once it’s needed.
How long does a TAVI valve last?
This is the question patients ask most, and the answer has become much clearer over the last few years.
- PARTNER 3, seven years: results have now been reported seven years after the procedure. The SAPIEN 3 valve has lasted as well as a surgical valve: the valve had failed in 6.9% of TAVI patients and 7.5% of surgical patients, which was not statistically significant [8]. Structural valve deterioration is where the leaflets of the new valve themselves wear out, so that on echo the valve becomes moderately or severely narrowed or leaky, as opposed to problems caused by blood clot or infection. It was almost identical: 7.3% compared with 7.6% (P=0.88) [9]. Overall, death, stroke or readmission to hospital was similar by seven years: 34.6% compared with 37.2%, which was not statistically significant [8].
- PARTNER 2, ten years: this shows how much the valves have improved. With the older SAPIEN XT valve, further valve treatment was needed more often than after surgery: 6.3% compared with 1.6% (P<0.001) [10]. Patients treated with the current SAPIEN 3 valve were compared with closely matched surgical patients. At ten years, further treatment had been needed equally rarely (2.0% compared with 1.9%, P=0.47), and survival was the same [11].
- NOTION, ten years: this Scandinavian trial used a different, self-expanding valve (CoreValve) and has the longest randomised follow-up. Severe structural valve deterioration is where the leaflets wear out enough to cause severe narrowing or leaking of the valve on echo. It was less common after TAVI than after surgery (1.5% compared with 10%, P=0.02). Valve failure was similar (9.7% compared with 13.8%, P=0.4) [12].
What happens if a TAVI valve wears out?
A worn TAVI valve can usually be treated with a second TAVI placed inside the first (TAV-in-TAV), rather than with open-heart surgery. In an international registry of 212 of these procedures, there were no deaths during the procedure, 1.4% of patients had a stroke, and 97% were alive at 30 days [13].
Is TAVI suitable for a bicuspid valve?
Some patients, particularly younger ones, have a bicuspid aortic valve, which has two leaflets instead of three.
- PARTNER 3 bicuspid registry: carefully selected low-risk patients with bicuspid valves received the SAPIEN 3 valve. At one year, the rate of death, stroke or readmission to hospital was the same as in matched patients with normal three-leaflet valves: 10.9% compared with 10.2% (P=0.80) [14].
- NOTION-2: the only randomised trial so far to include bicuspid valves, in patients aged 60 to 75. It looked at the combined rate of death, stroke or readmission to hospital because of the procedure, the valve or heart failure. In the 100 patients with bicuspid valves, this happened to 20.4% after TAVI and 7.8% after surgery by three years. The difference was not statistically significant, and the group was too small to tell whether it was real [15]. In patients with normal three-leaflet valves, the results were identical: 14.5% compared with 14.4%.
Bicuspid valves vary a great deal, and each one needs careful assessment with CT to decide whether TAVI or surgery is the better choice.
References
- NICOR. Transcatheter Aortic Valve Implantation (TAVI) Registry. Interim Report 2026: Procedure Urgency, including data up to 2024/25. National Cardiac Audit Programme 2026. https://www.nicor.org.uk/interactive-reports/transcatheter-aortic-valve-implantation-tavi-registry
- NICOR. National Adult Cardiac Surgery Audit (NACSA). Interim Report 2026. National Cardiac Audit Programme 2026. https://www.nicor.org.uk/interactive-reports/national-adult-cardiac-surgery-audit-nacsa
- Leon MB, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery (PARTNER 1B). New England Journal of Medicine 2010;363:1597–1607. doi:10.1056/NEJMoa1008232
- Smith CR, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients (PARTNER 1A). New England Journal of Medicine 2011;364:2187–2198. doi:10.1056/NEJMoa1103510
- Leon MB, et al. Transcatheter or surgical aortic-valve replacement in intermediate-risk patients (PARTNER 2A). New England Journal of Medicine 2016;374:1609–1620. doi:10.1056/NEJMoa1514616
- Mack MJ, et al. Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients (PARTNER 3). New England Journal of Medicine 2019;380:1695–1705, and supplementary appendix. doi:10.1056/NEJMoa1814052
- Blankenberg S, et al. Transcatheter or surgical treatment of aortic-valve stenosis (DEDICATE). New England Journal of Medicine 2024;390:1572–1583. doi:10.1056/NEJMoa2400685
- Leon MB, et al. Transcatheter or surgical aortic-valve replacement in low-risk patients at 7 years. New England Journal of Medicine 2026;394:773–783. doi:10.1056/NEJMoa2509766
- Ternacle J, et al. Seven-year valve durability with transcatheter or surgical aortic valve replacement (PARTNER 3). JAMA Cardiology 2026. doi:10.1001/jamacardio.2026.2299
- Thourani VH, et al. 10-year randomized outcomes of transcatheter or surgical aortic valve replacement in intermediate-risk aortic stenosis. Journal of the American College of Cardiology 2026;87:3309–3321. doi:10.1016/j.jacc.2026.03.169
- Nazif TM, et al. 10-year outcomes of SAPIEN 3 transcatheter aortic valve replacement or surgery in intermediate-risk patients. Journal of the American College of Cardiology 2026;87:3296–3308. doi:10.1016/j.jacc.2026.03.170
- Thyregod HGH, et al. Transcatheter or surgical aortic valve implantation: 10-year outcomes of the NOTION trial. European Heart Journal 2024;45:1116–1124. doi:10.1093/eurheartj/ehae043
- Landes U, et al. Repeat transcatheter aortic valve replacement for transcatheter prosthesis dysfunction. Journal of the American College of Cardiology 2020;75:1882–1893. doi:10.1016/j.jacc.2020.02.051
- Williams MR, et al. The PARTNER 3 bicuspid registry for transcatheter aortic valve replacement in low-surgical-risk patients. JACC: Cardiovascular Interventions 2022;15:523–532. doi:10.1016/j.jcin.2022.01.279
- Jørgensen TH, et al. Three-year follow-up of the NOTION-2 trial. Circulation 2025;152:1326–1337. doi:10.1161/CIRCULATIONAHA.125.076678