Aortic Valve Replacement vs. Balloon-Expandable and Self-Expandable Transcatheter Implantation in Low-Risk Patients

<b>Objectives:</b> This study sought to compare midterm outcomes of low-risk patients who underwent a surgical aortic valve replacement (SAVR) vs. balloon-expandable (BE) or self-expandable (SE) transcatheter aortic valve implantation (TAVI). <b>Methods:</b> Data on consecutive patients undergoing SAVR or transfemoral TAVI between 2017 and 2022 were collected. Patients were separated into three groups according to the type of prosthesis: a biological surgical prosthesis, BE prosthesis and SE prosthesis. The three groups were compared in terms of baseline characteristics, post-procedural outcomes and long-term survival. <b>Results:</b> A total of 542 patients were enrolled, and 221 received a surgical prothesis, 150 received a BE prosthesis and 171 received an SE prosthesis. TAVI patients were older and had a higher risk profile compared to surgical patients. Propensity score matching resulted in an excellent matching of nearly 80 patients in each group. In the matched cohort, SE prostheses were associated with a significantly higher incidence of stroke (SE group 6.3%, BE group 0, SAVR group 2.3%, <i>p</i> = 0.045), para-valvular leak (SE group 8.1%, BE group 2.4%, SAVR group 0, <i>p</i> = 0.017) and left bundle branch block (SE group 23.8%, BE group 18.2%, SAVR group 0%, <i>p</i> < 0.001). Regarding 5-year mortality, no significant differences were reported between the BE and SE TAVI (13.6% vs. 22.5%, <i>p</i> = 0.066). However, when comparing surgery versus TAVI, the SE prosthesis showed a significantly higher 5-year mortality (22.5% vs. 11.6%, <i>p</i> = 0.042). Instead, the BE prosthesis demonstrated its non-inferiority compared to the surgical prosthesis (13.6% vs. 11.6%, <i>p</i> = 0.249). <b>Conclusions:</b> The BE prosthesis should be considered the prosthesis of choice for patients with a long life expectancy requiring a transcatheter procedure.