New paradigms for the sequential treatment of severe aortic stenosis: imaging-guided selection of the first intervention paves the way for lifetime management

Not so long ago, towards the end of the last century, surgical aortic valve replacement (SAVR) with a mechanical prosthesis combined with lifelong anticoagulation using vitamin K antagonists (requiring regular haematological monitoring and with an attendant risk of bleeding) was the only treatment option for patients with severe aortic stenosis. The mainstream application of bioprosthetic surgical valves in the 1980s and 1990s presented a major breakthrough, allowing older patients at higher risk of bleeding the possibility of surgery without the need for lifelong anticoagulation. These patients were initially deemed unlikely to outlive their valve and the prospect of a second ...