From gradients to lifetime strategy: rethinking TAVI choice in small aortic roots

Over the past two decades, transcatheter aortic valve implantation (TAVI) has transformed the management of aortic stenosis and has become the emblem of structural heart innovation. What started as a rescue option for inoperable patients is now a mainstream therapy across the entire risk spectrum1. With expanding indications, particularly in lower-risk patients with an expected survival well beyond 10 years, a natural question arises: is the innovation cycle in TAVI complete, or are we just entering a new phase? Can what has been transformational be further refined by incremental innovation?

In the early TAVI era, success meant crossing the valve, avoiding catastrophes and achieving an acceptable gradient. Today, this is no longer enough. For both TAVI and surgical aortic valve replacement (SAVR) operators, the index valve procedure must be planned as the first step of a lifelong strategy. Short-term safety still matters enormously and depends on three elements: patient anatomy and comorbidities, device selection, and operator performance. But current aortic interventions should be planned and performed with a long-term perspective: prosthesis durability, coronary access, feasibility and safety of redo-TAVI or...