Evolution of Aortic Valve Replacement Across Two Eras: Institutional Changes in Transcatheter and Surgical Practice and Outcomes

Objectives: Conventionally, the gold standard for aortic valve disease has been surgical aortic valve replacement (SAVR). Advances in transcatheter aortic valve replacement (TAVR) have since produced marked improvements in both outcomes and procedural volume. We sought to characterize this evolution by comparing the earliest and most recent 100 procedures of each modality at a single high-volume institution. Methods: We retrospectively compared four cohorts of 100 consecutive isolated procedures: 100 TAVRs from 2012 (the earliest period of complete and verifiable registry capture) and 100 first-time SAVRs from a contemporaneous period (2011), each versus the 100 most recent procedures of the same modality (TAVR 2024; SAVR 2024–2025). The SAVR cohorts were limited to first-time, isolated replacement; the TAVR cohorts to native-valve procedures. The primary endpoint was the 30-day composite of death or stroke. Secondary endpoints included new permanent pacemaker implantation, paravalvular leak, vascular access route, anesthetic technique, and length of stay. Results: For TAVR, the 30-day composite of death or stroke fell from 10% to 1% (p = 0.010), with fewer in-hospital deaths (6% to 0%; p = 0.029) and less new dialysis (4% to 0%; p = 0.059). A paravalvular leak of at least mild severity fell from 27% to 3% (p < 0.001), with none as moderate or greater in either era. New pacemaker implantation decreased from 15% to 6% (p = 0.056). Within the same comparison, general anesthesia decreased from 100% to 23%, non-transfemoral access from 29% to 2%, median ICU stay from 43 to 0 h, and hospital stay from 6 to 1 day (all p < 0.001). SAVR outcomes remained similar (composite 2% to 0%, p = 0.497; pacemaker 1% to 0%; and paravalvular leak 0% to 4%), while prolonged ventilation (11% to 1%; p = 0.007) and hospital stay (8 to 5 days; p < 0.001) improved. The SAVR population became younger (74 to 64 years; p < 0.001), and isolated first-time surgery was markedly less frequent, requiring 18.9 versus 5.7 months to accrue 100 consecutive cases. Conclusions: In this two-era institutional comparison, recent-era TAVR outcomes were markedly better, while SAVR outcomes remained excellent in both eras within a recent population that was younger and in whom eligible isolated first-time surgery was less frequent. Because the eras differed substantially in patient risk profile, these unadjusted within-modality comparisons describe a real-world redistribution of aortic stenosis care between two increasingly complementary treatments rather than isolating the effect of any single procedural or technological factor.