Role of leaflet modification in TAVI: to prevent coronary obstruction only or potentially a routine practice?

Over the years, transcatheter aortic valve implantation (TAVI) has been increasingly offered to younger patients. The trend has been driven not only by technological advancement and rigorous clinical trials but also by patient demand for interventions that are less invasive, with lower risk and faster recovery. This is evidenced by the high proportion of patients under the age of 65 who undergo TAVI in the USA despite the guidelines recommending surgical aortic valve replacement (SAVR) in this age group1. Younger patients who undergo TAVI are more likely to require reintervention for bioprosthetic valve failure (BVF). If BVF occurs, treatment options are limited to surgical explant or a second TAVI inside the failed valve (redo-TAVI). Both treatment options carry risks. Explant surgery is associated with high mortality rates (with recent data showing a 30-day mortality rate of 16%2). Redo-TAVI risks coronary obstruction and makes future coronary access more challenging345. This is because when we perform redo-TAVI and deploy a transcatheter heart valve (THV) inside a failed THV, we push the degenerated leaflets of the first valve...