Evidence-based guidelines for aortic stenosis: Focus on surgical aortic valve replacement versus transcatheter aortic valve implantation for young patients

Abstract

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis and is now an established alternative to surgical aortic valve replacement (SAVR) for all surgical risk categories. However, the extension of TAVI to younger, low-risk patients has raised important questions regarding the long-term outcomes, valve durability, and lifetime management strategies for these patients. This narrative review summarizes the current evidence from pivotal randomized trials and contemporary registries comparing TAVI and SAVR in young, low-risk patients, integrating the latest 2025 ESC/EACTS guidelines. While short-term outcomes and early recovery favor TAVI, SAVR remains associated with proven durability, lower rates of conduction disturbances, and a potential advantage in long-term outcomes as follow-up data extend beyond five years. Anatomical challenges such as bicuspid valves, coronary access, and patient–prosthesis mismatch further complicate the use of TAVI in this population. A “SAVR-first” lifetime management approach appears to provide greater procedural flexibility and a lower reintervention risk. Ultimately, the choice between TAVI and SAVR in young patients should be individualized through a multidisciplinary Heart Team process, balancing early procedural benefits with long-term durability and reintervention considerations. This review highlights the need for dedicated long-term data and patient-tailored strategies in the evolving management of aortic stenosis in young low-risk individuals.