An Interpretable AI Tool for SAVR vs TAVR in Low to Intermediate Risk Patients with Severe Aortic Stenosis

Background. Treatment selection for low to intermediate risk patients with severe aortic stenosis between surgical (SAVR) and transcatheter (TAVR) aortic valve replacement remains variable in clinical practice, driven by patient heterogeneity and institutional preferences. While existing models predict postprocedural risk, there is a lack of interpretable, individualized treatment recommendations that directly optimize long-term outcomes. Methods. We introduce an interpretable prescriptive framework that integrates prognostic matching, counterfactual outcome modeling, and an Optimal Policy Tree (OPT) to recommend the treatment minimizing expected 5-year mortality. Using data from Hartford Hospital and St. Vincent's Hospital, we emulate randomization via prognostic matching and sample weighting and estimate counterfactual mortality under both SAVR and TAVR. The policy model, trained on these counterfactual predictions, partitions patients into clinically coherent subgroups and prescribes the treatment associated with lower estimated risk. Findings. If the OPT prescriptions are applied, counterfactual evaluation showed an estimated reduction in 5-year mortality of 20.3\% in Hartford and 13.8\% in St. Vincent's relative to real-life prescriptions, showing promising generalizability to unseen data from a different institution. The learned decision boundaries aligned with real-world outcomes and clinical observations. Interpretation. Our interpretable prescriptive framework is, to the best of our knowledge, the first to provide transparent, data-driven recommendations for TAVR versus SAVR that improve estimated long-term outcomes both in an internal and external cohort, while remaining clinically grounded and contributing toward a more systematic and evidence-based approach to precision medicine in structural heart disease.