Optimizing TAVI strategy: balancing predilatation benefits and direct implantation efficiency

Balloon aortic valvuloplasty (BAV) has historically been considered an integral step during transcatheter aortic valve implantation (TAVI), facilitating valve crossing and expansion, particularly in early-generation devices. However, advances in valve technology, delivery systems, and imaging have prompted a shift toward direct TAVI without routine predilatation. Contemporary evidence from randomized trials, large registries, and meta-analyses demonstrates that direct TAVI is feasible and safe in anatomically favorable cases, with comparable device success and early clinical outcomes to BAV-assisted implantation. Nonetheless, predilatation remains valuable in selected patients with complex anatomy, including severe leaflet calcification, high transvalvular gradients, bicuspid morphology, horizontal aorta, or challenging valve crossing. Predilatation may further improve procedural control, optimize valve expansion, and reduce residual paravalvular leakage, particularly with self-expandable valves and platforms with lower intrinsic opening force. Conversely, routine BAV may increase procedural complexity, radiation and contrast exposure, and embolic risk. Overall, current evidence supports a selective, anatomy-driven approach to predilatation, balancing procedural efficiency with optimal valve deployment and safety. This review critically examines the evolving role of BAV in contemporary TAVI practice.