Addressing unanswered questions in transcatheter aortic valve replacement: lifetime management, leaflet modification, and cerebral protection

Abstract

Transcatheter aortic valve replacement (TAVR) has rapidly evolved from a therapy reserved for high-risk surgical candidates to a preferred treatment option across a broad range of patients with severe aortic stenosis. Contemporary randomized trials have demonstrated comparable or superior early outcomes to surgical aortic valve replacement (SAVR), leading to expanded indications in intermediate- and low-risk populations, as well as select patients with bicuspid anatomy. Recent guideline updates, including the 2025 European Society of Cardiology recommendations, unify the age threshold for TAVR to ≥ 70 years in appropriately selected patients and support consideration of early intervention in asymptomatic severe aortic stenosis based on emerging evidence. As younger patients increasingly undergo TAVR, several key uncertainties have become central to clinical decision-making. Long-term valve durability beyond the first decade remains insufficiently defined, emphasizing the need for structured lifetime management strategies that account for anticipated reinterventions, prosthesis-patient mismatch, and coronary access preservation. The rise in valve-in-valve and redo-TAVR procedures introduces complex anatomical challenges, including coronary obstruction and sinus sequestration, which has driven the development of advanced leaflet-modification techniques. In parallel, the role of cerebral embolic protection (CEP) remains uncertain, as randomized trials have demonstrated neutral results, leading to ongoing investigation into which patients may benefit and which technologies may offer meaningful protection. This review synthesizes current evidence and unresolved questions in three domains essential to contemporary TAVR practice: lifetime management, leaflet modification strategies, and CEP.

Keywords

Transcatheter aortic valve replacement / lifetime management of aortic stenosis / leaflet modification / cerebral embolic protection

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