Traditional aortic valve replacement is open heart surgery. The most common surgical approach involves a 6-inch cut through the breastbone, stopping the heart temporarily, and connecting the patient to a heart-lung machine while the surgeon removes the damaged valve and sews in a new one. However, there are now less invasive options, including a catheter-based procedure that replaces the valve without opening the chest at all.
What Makes It Open Heart Surgery
Surgical aortic valve replacement, known as SAVR, follows the same basic pattern as other open heart procedures. The surgeon cuts vertically through the breastbone (a sternotomy) to expose the heart directly. A heart-lung machine takes over the job of circulating blood and delivering oxygen, which allows the surgical team to temporarily stop the heart using a special solution. With the heart still, the surgeon cuts out the damaged aortic valve and stitches a new one into place. The chest is then wired closed.
This is major surgery by any measure. It requires general anesthesia, a hospital stay of about a week, and a recovery period of four to twelve weeks before most people feel close to normal. Full recovery, including returning to work and resuming physical activity, typically takes one to three months.
The Catheter-Based Alternative: TAVR
Transcatheter aortic valve replacement (TAVR) accomplishes the same goal without opening the chest. A thin tube called a catheter is threaded through an artery, usually in the groin, and guided up to the heart. The new valve is delivered through the catheter and expanded into position inside the old valve, pushing the damaged leaflets out of the way. The heart keeps beating throughout.
Recovery is dramatically faster. Most people are walking, eating, and seeing visitors within six to eight hours. Hospital stays are typically one to two days rather than a week. Because there’s no chest incision to heal, the weeks of restricted movement and lifting limitations that follow open surgery are largely avoided.
Minimally Invasive Surgical Options
Between full open heart surgery and TAVR, there’s a middle ground. Some surgeons perform aortic valve replacement through smaller incisions using techniques like a mini-sternotomy, where only the upper portion of the breastbone is split, or a mini-thoracotomy, which uses a 2- to 3-inch cut in the right side of the chest. Robot-assisted approaches also exist. These still involve directly accessing the heart and are considered surgery, but the smaller incisions generally mean less pain and a somewhat faster recovery compared to a full sternotomy.
How Doctors Decide Which Approach You Get
Age is the single biggest factor in choosing between TAVR and open surgery. For patients over 80, TAVR is the default in most cases. For patients under 65 to 70, open surgery remains the standard recommendation. The reason comes down to valve durability: tissue valves last roughly 15 years, and TAVR is a newer procedure without enough long-term data to guarantee its valves hold up for decades. A 55-year-old would likely need at least one more replacement in their lifetime, and starting with a surgically placed valve gives more options down the road.
For patients between roughly 70 and 80, the decision becomes more individualized. Doctors weigh factors like overall health, heart anatomy, the presence of other conditions, and patient preference. The choice is no longer driven primarily by surgical risk scores. TAVR was originally approved only for patients too sick to undergo open surgery, but it has since expanded to patients at all risk levels.
Risks of Each Approach
Both procedures are remarkably safe today. Thirty-day mortality rates are very low for both: around 0.2% for open surgery and 0.4% for TAVR in patients under 60, for example. Overall complication rates have dropped significantly over the past decade. Between 2012 and 2019, the rate of at least one major complication following elective aortic valve replacement fell from 49% to 22%. TAVR saw the steepest improvement, with complications dropping from 41% to 19%.
The specific risks differ between the two procedures. TAVR’s most common complication is the need for a permanent pacemaker afterward, which happens when the new valve presses on the heart’s electrical conduction system. Open surgery carries higher rates of acute kidney injury and new irregular heart rhythms (atrial fibrillation), both of which relate to the stress of the longer procedure and the use of the heart-lung machine. Infection risk is also lower with TAVR, since there’s no large incision.
One nuance worth knowing: while TAVR complication rates dropped dramatically over the study period, complication rates for open surgery improved only modestly (from 51% to 47%). This likely reflects the fact that TAVR technology and technique evolved rapidly during those years, while open surgery was already a mature procedure.
What Recovery Looks Like
After open surgery, you’ll spend time in an intensive care unit before moving to a regular hospital room. Most people stay in the hospital about a week. Once home, you’ll have lifting restrictions (typically nothing over 5 to 10 pounds) while your breastbone heals, which takes roughly six to eight weeks. Driving, returning to work, and resuming exercise happen gradually over that period. Cardiac rehabilitation is commonly recommended to rebuild stamina safely.
After TAVR, the hospital stay is one to two days. You’ll have a small puncture site in your groin to watch for bleeding, but there are no bone-healing restrictions. Most people return to normal activities much sooner, though your care team will still want follow-up visits to check how the new valve is functioning.
Regardless of the approach, you’ll need regular monitoring of your replacement valve for the rest of your life, typically through periodic echocardiograms. If you receive a tissue valve, whether placed surgically or via catheter, it will eventually wear out and may need to be replaced again years later.