This article is based on an interview conducted by Radcliffe Cardiology with Dr Rui Campante Teles, Head of the Structural Heart Disease Programme at Hospital de Santa Cruz, Lisbon, Portugal.
Key Take-home Messages
- TAVI is increasingly considered for selected younger, lower-risk patients with severe symptomatic aortic stenosis, but anatomical assessment remains central to Heart Team decision-making.
- Lifetime management after TAVI should begin before the index procedure, with careful attention to valve hemodynamics, coronary re-access, paravalvular leak, permanent pacemaker risk and future redo-TAVI feasibility.
- The index valve matters: device selection, implantation strategy and commissural alignment may influence future coronary access, valve-in-valve planning and long-term treatment options.
As transcatheter aortic valve implantation (TAVI; TAVR) continues to move into younger, lower-risk patients with severe symptomatic aortic stenosis, the focus of discussion is evolving. Questions that once centered on procedural safety and early outcomes are increasingly being replaced by concerns about lifetime management after TAVI, valve durability, coronary access after TAVI and the feasibility of future reinterventions.
These issues now sit at the center of one of the most important debates in structural heart disease: how should Heart Teams treat patients who may live for decades after their first valve intervention? Recent evidence from low-risk trials, dedicated younger-patient analyses and lifetime management reviews has brought this question into sharper focus. Maturing data support the role of TAVI in selected lower-risk patients, but long-term evidence in truly younger cohorts continues to evolve (Rao et al. 2024; Jørgensen et al. 2025; Ternacle et al. 2026).
In conversation with Radcliffe Cardiology, Dr Rui Campante Teles, Head of the Structural Heart Disease Programme at Hospital de Santa Cruz in Lisbon, discussed the practical factors that increasingly shape treatment decisions in this population. His perspective reflects the reality now facing many Heart Teams: TAVI is no longer only about achieving an excellent immediate procedural result; it is about ensuring that the first procedure does not compromise future coronary intervention, redo-TAVI or long-term valve performance.
“Compared to some years ago, we now have evidence that this is a very good therapy as first-line for younger patients.”
That confidence is supported by maturing evidence in lower-risk patients, while dedicated long-term data in younger cohorts continue to evolve. The direction of travel is clear: TAVI is becoming a serious option for selected younger patients, but it requires a more deliberate, anatomy-led and future-facing strategy.
Anatomy Remains the First Decision Point
For Dr Campante Teles, the first question is not simply whether a patient is low risk. It is whether the anatomy is suitable for TAVI.
“We try to figure out if the anatomy is favorable for TAVI. If it is, I think it is an acceptable first-line treatment according to the evidence.”
This distinction is important. In younger, lower-risk patients, anatomy may be just as important as surgical risk when deciding between TAVI and surgical aortic valve replacement (SAVR). Annular dimensions, leaflet morphology, calcium distribution, coronary height, sinus anatomy and the presence of bicuspid aortic valve disease can all influence procedural risk and long-term planning.
Dr Campante Teles highlights heavily calcified bicuspid anatomy, eccentric calcification and markedly elliptical annuli as features that may still favor surgery. This is consistent with the more cautious interpretation of recent NOTION-2 data. In low-risk patients aged ≤75 years, NOTION-2 reported similar 1-year rates of death, stroke or rehospitalization overall, but also showed higher rates of non-disabling stroke, permanent pacemaker implantation and moderate or greater paravalvular regurgitation after TAVI compared with surgery. The investigators concluded that outcomes in younger bicuspid AS patients warrant caution and further investigation (Jørgensen et al. 2025).
A dedicated NOTION-2 substudy in patients aged ≤70 years further underlined this point. In patients with tricuspid AS, the risk of death, stroke or rehospitalization at 1 year was similar after TAVR and SAVR; however, in patients with bicuspid AS, TAVR was associated with a significantly higher risk of adverse outcomes. The authors described these analyses as exploratory but emphasized the need to tailor the intervention according to clinical risk, life expectancy, native valve morphology and anticipated risks with TAVR or SAVR (Jørgensen et al. 2025).
For expert Heart Teams, the implication is practical: younger age should not automatically push treatment toward TAVI, and low surgical risk should not automatically push it toward surgery. The decision should be individualized around anatomy, life expectancy, coronary access and the likely future treatment sequence.
Coronary Re-access Should Be Planned Before the First Valve Is Implanted
One of the strongest themes in Dr Campante Teles’ comments is the importance of coronary access after TAVI.
“Even if the patient doesn’t present coronary artery disease, we have to be sure that we can have an access that allows us to perform a catheterization and eventually a PCI.”
This is especially relevant in younger patients, who may have no significant coronary artery disease at the time of TAVI but may require coronary angiography or PCI years later. As TAVI expands into patients with longer life expectancy, coronary re-access is no longer a secondary technical consideration; it is part of the lifetime management plan.
Recent lifetime management reviews support this approach. They emphasize that preprocedural CT should be used not only to plan the index procedure but also to anticipate future coronary access, redo-TAVI feasibility, coronary obstruction risk and sinus sequestration (Rao et al. 2024).
Dr Campante Teles notes that device choice is central to this issue. In practice, Heart Teams may favor short-frame valves or longer-frame platforms with large cells when future coronary access is a major concern. However, valve selection should not be reduced to frame height alone. Coronary access may also be influenced by leaflet position, commissural alignment, implantation depth, sinus dimensions, coronary height and the relationship between the transcatheter heart valve and the native aortic root.
For operators, the practical question becomes: if this patient presents with acute coronary syndrome or requires coronary angiography in 5, 10 or 15 years, will the coronaries still be reachable?
Durability Starts With the Index Procedure
As TAVI moves into patients with longer life expectancy, long-term valve durability after TAVI has become one of the defining questions in structural heart disease.
For Dr Campante Teles, durability is not determined by valve design alone. It is also shaped by the quality of the index procedure.
“We have to expand the valve and ensure that there is no PVL around the valve because that is also problematic in the long term.”
This is a practical point for expert operators. The goal of the index procedure is not only a successful implant. It is to optimize the conditions that may support long-term valve performance.
Key procedural priorities include:
- achieving optimal transcatheter heart valve expansion;
- minimizing paravalvular leak;
- preserving coronary re-access;
- reducing the risk of permanent pacemaker implantation;
- optimizing valve hemodynamics;
- avoiding patient–prosthesis mismatch;
- anticipating redo-TAVI or valve-in-valve feasibility.
These priorities are consistent with recent lifetime management guidance, which identifies effective orifice area, paravalvular regurgitation, pacemaker risk, coronary obstruction, annular rupture, patient–prosthesis mismatch, conduction abnormalities and coronary reaccessibility as central considerations when planning TAVI in patients likely to outlive their first valve (Rao et al. 2024).
The emphasis on durability is also aligned with recent valve durability literature. The PARTNER 3 7-year durability analysis frames bioprosthetic valve durability as increasingly important as TAVR is considered for younger and lower-risk populations (Ternacle et al. 2026). This supports a cautious but forward-looking message: evidence is maturing, but durability in younger patients with longer life expectancy remains a key area of ongoing evaluation.
The Index Valve Matters
Perhaps the clearest practical message from Dr Campante Teles is that the index valve matters.
In younger patients, the first valve may shape almost every future option. It may affect coronary access, valve-in-valve feasibility, redo-TAVI planning, hemodynamic performance, pacemaker risk and the complexity of any subsequent intervention.
“The anatomy is key for the future durability of the valves.”
This is where device selection becomes a strategic decision rather than a purely procedural one. In patients with smaller annuli, supra-annular valve designs may help optimize hemodynamics. In heavily calcified anatomy, operators may need a device capable of achieving adequate expansion. In patients at risk of future coronary intervention, frame design, cell size, implantation depth and commissural alignment may become particularly important.
The latest practical guidance on lifetime management supports this approach. It states that the initial priority is to optimize the index procedure by maximizing transcatheter heart valve hemodynamic function and durability, minimizing permanent pacemaker risk, reducing paravalvular regurgitation and preventing coronary obstruction and annular rupture. It also highlights the need to plan for TAVI-in-TAVI, including risks of patient–prosthesis mismatch, conduction abnormalities, coronary obstruction and sinus sequestration (Rao et al. 2024).
For expert Heart Teams, this means that the index procedure should answer several questions before the valve is selected:
- Is the native anatomy favorable for TAVI?
- Is valve expansion likely to be complete and symmetric?
- Is the annulus small enough to raise concern about patient–prosthesis mismatch?
- Will coronary access remain feasible after implantation?
- Is commissural alignment achievable and clinically relevant in this case?
- What would a redo-TAVI strategy look like?
- Would surgery offer a better lifetime sequence for this patient?
These questions are especially important in younger, lower-risk patients because the first decision may determine the feasibility and safety of the second.
A Practical Framework for Heart Teams
For Heart Teams expanding TAVI into younger and lower-risk patients, Dr Campante Teles’ comments point toward a practical decision framework.
First, define whether the patient is anatomically suitable for TAVI. This should include detailed CT assessment of annular size, leaflet morphology, calcium distribution, coronary height, sinus dimensions, sinotubular junction anatomy and bicuspid features.
Second, determine whether TAVI preserves future treatment options. This includes future coronary angiography, PCI, redo-TAVI, TAVI-in-TAVI and possible surgical explant.
Third, select the valve according to the patient’s lifetime pathway, not only the immediate procedural result. This means considering hemodynamics, frame design, leaflet position, commissural alignment, coronary re-access and patient–prosthesis mismatch.
Fourth, involve the patient in the decision. Younger patients may reasonably prioritize faster recovery, but they should also understand the uncertainty around long-term durability, the possibility of future reintervention and the implications of choosing TAVI versus SAVR as the first procedure.
This is where the Heart Team discussion becomes most valuable. The question is no longer simply “Can we do TAVI?” but “Does TAVI provide the best lifetime strategy for this individual patient?”
Looking Ahead
The rapid evolution of transcatheter aortic valve implantation has transformed the management of severe symptomatic aortic stenosis. What was once reserved for elderly or high-risk patients is now increasingly considered in selected younger and lower-risk populations.
However, as Dr Campante Teles makes clear, the expansion of TAVI into younger patients demands a more rigorous approach to anatomical assessment, valve selection and lifetime planning.
“What is new currently is that compared to some years ago, we have now evidence that this is a very good therapy as first-line for younger patients.”
For expert Heart Teams, the practical message is clear: procedural success is no longer enough. In younger, lower-risk patients, the first TAVI procedure must be planned with the next decade of care in mind.
That means preserving coronary re-access, optimizing valve hemodynamics, minimizing PVL and pacemaker risk, anticipating redo-TAVI feasibility and selecting the index valve with a lifetime management strategy already in place.
As TAVI continues to expand, the most important decision may not be whether the valve can be implanted successfully today. It may be whether the valve selected today preserves the best options for tomorrow.
References
- Rao K, Baer A, Bapat VN, Piazza N, Hansen P, Prendergast B, Bhindi R. Lifetime management considerations to optimise transcatheter aortic valve implantation: a practical guide. EuroIntervention. 2024;20:e1493–e1504.
- Jørgensen TH, et al. Transcatheter aortic valve implantation in low-risk tricuspid or bicuspid aortic stenosis: the NOTION-2 trial. European Heart Journal. 2024;45:3804–3814.
- Jørgensen TH, et al. Transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis aged 70 years or younger: A NOTION-2 substudy. American Heart Journal. 2025;284:67–70. PMID: 39952377.
- Ternacle J, et al. Seven-Year Valve Durability With Transcatheter or Surgical Aortic Valve Replacement: An Ad Hoc Analysis of the PARTNER 3 Randomized Clinical Trial. JAMA Cardiology. 2026. PMID: 42340728.