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 — in the case of England’s Henry Souttar — many consider the years since 1990 the “golden age” of these life-changing procedures.

Minimally invasive cardiac procedures such as transcatheter aortic valve replacement (TAVR), catheter-based mitral valve repair, and percutaneous atrial septal defect closure fail at times to attract the same attention given to traditional open-heart surgeries, particularly high-profile procedures such as a coronary artery bypass graft. Studies like this 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 this review article 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 as compared to patients undergoing full sternotomy. They go on to say that 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 now can be done in under an hour and often without general anesthesia. The surgical wound for the procedures is less than a 1-cm incision,” said Paul Sorajja, MD, an interventional cardiologist at Banner - University Medical Center in Phoenix. “There is no compromise in terms of safety or procedure risk. Patients can therefore 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 such as depression, anxiety, and PTSD [posttraumatic stress disorder] occur more frequently in patients undergoing open heart surgery than those who opted for minimally invasive procedures,” Rudin said. “Cardiac surgery is also a mental health emergency.”

Roderick Tung, MD, director of the Cardiovascular Center at Banner - University Medical Center in Phoenix, 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 1-2 years with their aortic stenosis.”

Recent Studies on TAVR Outcomes

On March 30, 2025, JACC published this review article that showed that 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.

Further, 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 noninferior 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 this 2023 article in TCTMD, the publication of the Cardiovascular Research Foundation, Kendra Grubb, MD, the surgical director of the Emory Structural Heart and Valve Center 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 2- to 3-year timepoint. Personally, it’s a red flag…I think the exuberant statements made at the 1-year point where there was superiority [with TAVR over SAVR] have been called into question. If you go back to that 1-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 April 3, 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 the study period, 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 1 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 to 92% of the trial-eligible group.

The study team said that differences in these rates were likely 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 really we’re looking at is patients’ anatomic risks,” said Gilbert Tang, MD, surgical and academic director of the Structural Heart Program, 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 that 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.”