Lifetime Management of Aortic Stenosis: Expert Review of Evidence and Consensus Guidelines

The 2025 European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines introduced a Class I recommendation for transfemoral transcatheter aortic valve implantation (TAVI) in selected patients aged 70 years or older with tricuspid aortic stenosis and suitable anatomy, while surgical aortic valve replacement (SAVR) remains recommended in younger low-risk patients. In patients with long expected survival, this framework requires careful consideration of valve durability, future reintervention, and patient preferences. This expert review, developed by the Italian Cardiac Surgery Working Group, examines contemporary evidence and consensus recommendations from a lifetime-management perspective. We performed a narrative, evidence-based synthesis of randomized trials, trial-based meta-analyses, and propensity-matched real-world registries comparing transfemoral TAVI and SAVR, with primary emphasis on low-risk patients. Lower-intermediate-risk evidence was included only when directly relevant to lifetime management, durability, or reintervention. Evidence suggests that treatment effects are time-dependent: early non-inferiority of TAVI may attenuate with longer follow-up, particularly in patients with substantial life expectancy. Randomized durability data remain limited, whereas propensity-matched real-world registries have suggested possible higher late mortality after TAVI in younger, lower-risk populations. Reintervention after a transcatheter-first strategy may be associated with increasing technical complexity and procedural risk over time. This review supports appropriate application of current guidelines through a pragmatic framework for individualized, Heart Team-based decision-making. Transfemoral TAVI is often appropriate in patients with limited life expectancy or recognized high surgical risk when anatomically feasible. In patients with long expected survival, SAVR should retain a central role as an important reference strategy.