Transcatheter aortic valve implantation: contemporary management from first valve choice to reintervention

Transcatheter aortic valve implantation (TAVI) has evolved from a last resort for inoperable aortic stenosis into the preferred bioprosthetic strategy across much of the surgical-risk spectrum for anatomically suitable patients. As it expands into younger and lower-risk populations, the central question is no longer whether TAVI can be performed, but how to choose the first valve intervention so that future options remain open. This clinical perspective focuses on practical decision-making: which patients are better served by TAVI or surgical aortic valve replacement (SAVR), how computed tomography planning influences both immediate and lifetime outcomes, how to manage common early issues such as conduction disease and coronary access, and how to recognise valve dysfunction and plan reintervention. Rather than treating the choice between TAVI and SAVR as a single episode, we consider it as the first step in a treatment sequence. After implantation, ongoing outcomes are shaped by rhythm surveillance, optimisation of antithrombotic and heart failure therapy and early detection of leaflet thrombosis, endocarditis or structural valve degeneration. Contemporary aortic valve replacement practice therefore requires choosing the first procedure with the likely next procedure already in mind.