Lifetime Management of Aortic Stenosis: Evolving Strategies and Personalized Decision-Making

Figures

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  Figure 1. The Ross Procedure: Panel (A) details a summary of patient selection and key surgical approaches for the Ross operation. Ideal candidates are younger, active patients with favorable aortic anatomy. The pulmonary autograft in the aortic position can be performed with two different techniques. A: The Ross procedure process is shown along with the strengths and limitations. B: Indications, patient selection, and contraindications for the Ross procedure. Panel (B) illustrates the subcoronary technique. A: Subcoronary technique. B: Full root replacement technique. Panel (C) illustrates full root replacement techniques along with modern reinforcement strategies designed to reduce late autograft dilation. A: Autologous reinforcement technique; B: Dacron reinforcement technique; C: Extra-aortic annuloplasty with interposition graft. Adapted with permission from Ref. [13] under license from Elsevier and Copyright Clearance Center in 2026.

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  Figure 2. The 2025 ESC/EACTS Valvular Heart Disease Guidelines section on management of aortic stenosis. The 2025 ESC/EACTS developed updated valvular guidelines that detail key factors influencing the initial choice between SAVR, TAVI, mechanical valves, bioprostheses, and the Ross procedure. Decision-making incorporates age, anatomy, comorbidities, technical feasibility, and lifetime valve planning. Adopted from 2025 ESC/EACTs Valvular Heart Disease. (a The original figure states that relative contraindications to TAVR are LV thrombus and infective endocarditis. b The original figure indicates that lifetime management for aortic stenosis is especially important for patients in whom anticipated life expectancy is thought to exceed the durability of the valve.) Ref. [3] with permission under license from Oxford University Press License in 2026.

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  Figure 3. Lifetime Management Framework for Initial and Re-do Aortic Valve Interventions in Severe Aortic Stenosis. Deliberate planning of the index procedure is fundamental to lifetime management in severe aortic stenosis. This figure illustrates a lifetime management approach to severe aortic stenosis: emphasizing importance of index procedure, integrating Heart Team assessment, key anatomic and clinical variables, and ultimately patient preference. Initial SAVR or TAVR informs re-intervention strategies such as TAVR ViV, Redo TAVR, redo SAVR, or TAVR explant. Original figure created by the authors of this paper.

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  Figure 4. Alternative Approaches When Aortic Valve Explant is Not an Option. In patients with high-risk anatomy and prohibitive surgical risk, adjunctive strategies are the next best step. These include techniques such as BASILICA leaflet laceration, Pi-Cardia leaflet modification, or chimney stenting. Panel (A) shows a schematic illustration of BASILICA performed in native aortic stenosis where intentional leaflet laceration prior to transcatheter valve deployment prevents sinus sequestration and preserves coronary flow. Additionally, in degenerated bioprosthetic valves, leaflet laceration facilitates safe valve-in-valve TAVR by preventing displacement of the leaflet against the sinotubular junction and coronary ostia, reducing the risk of coronary obstruction. Panel (B) shows successful leaflet laceration that allows for coronary stents to be deployed orthotopically through the transcatheter heart valve frame (THV), thus maintaining native coronary access. In the absence of leaflet modification, coronary protection may require stent deployment behind the THV frame, resulting in snorkel configuration. Panel (C) shows a fluoroscopic demonstration of leaflet laceration and preserved…

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  Figure 5. Favorable Case for Redo TAVR. (A) Index TAVR Procedure. Favorable TAVR anatomy for index procedure, characterized by suitable annular dimensions, adequate sinus of Valsalva and STJ size, safe coronary heights, absence of high-risk calcification, and supportive 3D sinus geometry. (B) TAVR with structural valve deterioration. Several years later, CT imaging demonstrates structural valve deterioration. Elevated gradients also seen by echocardiography and patient noted symptomatic. Redo TAVR is favorable given adequate sinus and STJ dimensions, safe coronary heights, and sufficient valve-to-coronary clearance. (C) Fluoroscopic Imaging of TAVR-in-TAVR Implantation. Sequential fluoroscopic images of a patient who had a TAVR valve 7 years prior with structural valve deterioration. This illustrates positioning and deployment of the new transcatheter valve within the prior TAVR valve prosthesis, demonstrating stable coaxial alignment, and adequate frame expansion within the existing valve structure. (D) DASI (Dynamic Aortic Sinus Interaction) simulation of BE TAVR 23 in BE TAVR 23 Expansion showing favorable TAVR in TAVR. Panel (E): DASI simulation of SE TAVR 26 in BE TAVR 23. Expansion…

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  Figure 6. An Unfavorable Case for Re-do TAVR. Pre-procedure CT scan of TAVR valve deterioration showing high-risk anatomy noted by the sinus sequestration which occurs with small valve-to aorta clearance at the STJ (<2 mm) which can jeopardize re-access. Example of TAVR CT images from authors’ institution.

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  Figure 7. Key Determinants Influencing Lifetime Aortic Valve Management. This diagram highlights the interplay of growing clinical expertise, ongoing technological innovation, and expanding clinical evidence that guides the modern management of aortic stenosis. Important challenges remain throughout the lifespan of a bioprosthetic valve. These include structural valve degeneration, limitations in coronary access, pacemaker requirement, paravalvular leak, and prosthesis–patient mismatch. These challenges may accumulate over time and ultimately necessitate repeat intervention. Accordingly, thoughtful planning of the initial valve procedure is essential, with careful attention to anatomical feasibility, valve type, and future reintervention options. Aortic valve replacement should be approached as a lifetime strategy rather than a single procedural event, anticipating the possibility of sequential therapies as patients live longer with valve disease. Original figure created by the authors.