While the first innovators in the area of minimally invasive cardiac procedures began introducing methods such as finger-fracture valvuloplasty as early as the 1920s, many consider the years since 1990 the “golden age” of these life-changing procedures, reports Medscape.
Minimally invasive cardiac procedures such as transcatheter aortic valve replacement (TAVR), catheter-based mitral valve repair, and percutaneous atrial septal defect closure, often fail to attract the same attention given to traditional open-heart surgeries, particularly high-profile procedures such as a coronary artery bypass graft.
Studies like one from the March 2021 issue of the Journal of Thoracic Disease discuss the debate over outcomes, quality, and safety that has followed these procedures.
Conversely, the authors of another review published in Current Opinion in Anesthesiology pointed out that several current forward-looking and retrospective trials demonstrate reduced length of stay (LOS) for patients who have undergone these minimally invasive procedures compared with patients undergoing full sternotomy.
They said reviews and meta-analyses indicate that “minimally invasive cardiac surgery (MICS) is associated with reduced atrial fibrillation, wound complications, blood transfusion, LOS, and potentially cost”.
Additionally, several new trials reporting longer-term follow-up on MICS coronary and valve surgery have demonstrated durable results.
Emerging literature on the benefits of combining MICS and Enhanced Recovery After Surgery perioperative protocols have also reported promising results regarding reduced LOS and faster recovery.
“The changes from open surgery to transcatheter therapy have been quite remarkable – a lifesaving therapy can now be done in under an hour and often without general anaesthesia. The surgical wound for the procedures is less than a 1cm incision,” said Paul Sorajja, MD, an interventional cardiologist at Banner University Medical Centre in Phoenix.
“There is no compromise in terms of safety or procedure risk. Patients can then recover quickly and be discharged home the next day. The minimally invasive nature of these procedures allows patients to return to their daily activities almost immediately with all the benefits of having a lifesaving therapy that also significantly improves their symptoms.”
Andrew Rudin, MD, of Scottsdale, Arizona-based Natural Heart Doctor, said psychological issues are often overlooked when comparing outcomes between these two types of procedures.
“Issues like depression, anxiety, and PTSD (post-traumatic stress disorder) occur more frequently in patients undergoing open heart surgery than those opting for minimally invasive procedures,” he said. “Cardiac surgery is also a mental health emergency.”
Roderick Tung, MD, director of the Cardiovascular Centre at Banner University Medical Centre, said this procedure is incredibly successful.
“For TAVR, success rates are 98%, risk of stroke is 1%-2%, risk of a pacemaker is about 5%-10%. Without TAVR, patients do not survive one to two years with their aortic stenosis.”
Studies on TAVR outcomes
Earlier this year (30 March 2025), JACC published an article that showed patients who received the TAVR procedure and those who received the surgical aortic valve replacement (SAVR) procedure had comparable rates of all-cause mortality or disabling stroke.
Furthermore, the durability and performance of the valve installed in both procedures was “excellent”. The team concluded that “(t)his midterm evaluation reinforces the position of TAVR as non-inferior to surgery in patients with severe aortic stenosis at low surgical risk”.
They plan to perform the same review again at the 10-year mark to make further assessments.
In a TCTMD article article in 2023, the publication of the Cardiovascular Research Foundation, Kendra Grubb, MD, surgical director of the Emory Structural Heart and Valve Centre in Atlanta, said the later data called for more consideration regarding this specific procedure.
“Statistically speaking, there was no difference in mortality, but the curves cross at that two- to three-year timepoint. Personally, it’s a red flag…I think the exuberant statements made at the one-year point where there was superiority [with TAVR over SAVR] have been called into question. If you go back to that on1-year data, where TAVR first for everyone was the message, now we have to be a little bit more thoughtful.”
These are trial populations: what about how these devices and others do out in the real world?
A team looked at this question in a research article published in the 3 April 2025 issue of the journal Circulation, using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Registry to evaluate outcomes of low-risk TAVR patients in the US during the study period January 2020 to March 2024.
Among 383 030 patients who underwent TAVR during this time, 108 407 were designated low risk by the heart team and 68 194 met other study inclusion and exclusion criteria. Of these, 42 093 (62%) would have been eligible for the low-risk trials.
At the 30-day mark, the mortality rate was at 0.8% of the population designated low risk by the study team, and 0.6% for the trial-eligible population; the stroke rate was 1.5% in the low-risk group and 1.4% in the trial-eligible group; and 8.4% of the low-risk group required new permanent pacemakers within 30 days.
At one year:
• The mortality rates of the population designated low risk by the study team and trial-eligible population were 4.6% and 3.1%, respectively.
• 2.6% and 1.4% of the population designated low risk by the study team and trial-eligible population, respectively, had succumbed to stroke.
Overall, 90% of the study team low-risk group were classified “alive and well” compared with 92% of the trial-eligible group.
The study team said that differences in these rates were possibly attributable to “greater comorbidity burden”, and they illuminate the opportunities for “improvement in longitudinal care after low-risk TAVR in the community”.
The latter point correlates with other research on the importance of coordinated care in complex patients.
“Currently, the guidelines suggest that TAVR is indicated in patients across all surgical risks, so what we’re really looking at is patients’ anatomic risks,” said Gilbert Tang, MD, surgical and academic Director of the Structural Heart Programme, System Director of mitral and tricuspid structural intervention at the Mount Sinai Health System, Professor and Vice Chair of Innovations in the Department of Cardiovascular Surgery, and Professor in the Department of Medicine/Cardiology at the Icahn School of Medicine at Mount Sinai in New York City.
“The way we determine that is with a CAT scan we do routinely on these patients to see what the anatomy looks like in terms of what type of device would fit and any other high-risk features that would compromise the outcome.
“After that, we discuss with the patient what we call ‘lifetime management’ of a new prosthetic valve, whatever that might be, whether that’s surgical or transcatheter.”
See more from MedicalBrief archives:
Less than one-third of patients have rehabilitation after TAVR – US study
TAVR a durable remedy for those not eligible for open heart surgery