Approaches to transcatheter aortic valve replacement failure: is more focus on prevention required?

INTRODUCTION: Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis across all surgical risk strata. As its use expands to younger, lower-risk patients, the durability of transcatheter heart valves and the clinical consequences of prosthetic failure have become critically important. Despite a growing literature on reintervention strategies, systematic prevention of TAVR failure remains comparatively underemphasized. AREAS COVERED: We searched PubMed and the Cochrane Library (2000-2026, English language) for studies on TAVR failure and its prevention. This review examines the mechanisms of TAVR failure, including structural valve deterioration, paravalvular leak, prosthesis-patient mismatch, subclinical leaflet thrombosis, valve endocarditis, and device migration; appraises current management, including valve-in-valve TAVR, redo surgical aortic valve replacement, and medical therapy; and reviews prevention strategies spanning patient selection, procedural optimization, antithrombotic management, structural surveillance, coronary access preservation, and lifetime planning. EXPERT OPINION: The evidence base has focused disproportionately on reintervention rather than prevention. Greater emphasis on structured lifetime management planning at index TAVR, individualized antithrombotic strategies, and evidence-based surveillance is needed. Several proposed measures, however, including routine anticoagulation for subclinical leaflet thrombosis and routine CT or artificial-intelligence-based surveillance, are not yet supported by outcome data and require prospective validation.