Management of aortic stenosis: lifetime management is a moving target

We read with great interest the thoughtful article by Hamana and colleagues regarding lifetime management and reintervention after transcatheter aortic valve replacement (TAVR) (1). Their review appropriately highlights the growing importance of structural valve deterioration as TAVR expands into younger and lower-risk populations and provides an excellent overview of the pathological mechanisms underlying bioprosthetic valve failure. We agree that reintervention is no longer an exceptional event but an anticipated component of caring for patients with severe aortic stenosis. We would, however, like to expand the discussion from a surgical perspective by emphasizing three considerations: the evolving concept of lifetime management, the role of surgical TAVR explantation within that paradigm, and the unique challenge of interpreting evidence in a field where technology evolves faster than clinical trials.

Perhaps the most important observation is that “lifetime management” itself is a remarkably recent concept. Before TAVR was extended to younger and lower-risk patients, surgical aortic valve replacement (SAVR) was generally considered definitive therapy for most patients, and the phrase “lifetime management” was not even present before 2020. The concept emerged largely because transcatheter aortic valves began to be implanted in patients expected to outlive their initial prosthesis. While the terminology has become ubiquitous, it is important to recognize that lifetime management is not an established treatment algorithm but rather a framework intended to optimize the sequence of interventions throughout a patient's life. Consequently, the goal should not simply be preserving future treatment options but maximizing lifetime survival, valve durability, and procedural safety across multiple anticipated interventions.

Current discussions often frame lifetime management as a comparison between a SAVR-first and a TAVR-first strategy, with the implicit assumption that TAVR-first commits patients to repeat transcatheter interventions whereas SAVR-first preserves future flexibility. We believe this dichotomy is becoming increasingly outdated. Surgical TAVR explantation with redo SAVR (TAVR explant) has historically been regarded as a rescue operation with prohibitive mortality; however, accumulating experience from dedicated centers suggests that the procedure has evolved substantially over the past decade. Contemporary surgical techniques have become increasingly standardized, operative mortality continues to improve, and many patients can undergo successful TAVR explant even if requiring concomitant procedures. At the same time, important uncertainties remain regarding the long-term durability of valve-in-valve TAVR within failed surgical prosthesis (TAV-in-SAV) and redo TAVR (TAV-in-TAV), particularly in younger patients who may require multiple future interventions over decades.

Accordingly, TAVR-first followed by planned TAVR explant should no longer be viewed as a devastating situation but, for appropriately selected patients, may represent a reasonable or even superior lifetime strategy. The question therefore extends beyond whether TAVR can be implanted safely today; it is whether the entire sequence of therapies can be completed safely throughout the patient's lifetime. As TAVR explant continues to mature, the therapeutic pathway increasingly includes TAVR implantation followed, when necessary, by elective surgical explantation and definitive reconstruction.

This evolving paradigm also changes how we should interpret the existing comparative literature. The apparent long-term survival advantage of redo SAVR over TAV-in-SAV remains difficult to interpret because of substantial differences in baseline patient characteristics, residual selection bias, and the absence of randomized comparisons. Ongoing studies such as the REPEAT trial will hopefully clarify these uncertainties. Until then, superiority of one reintervention strategy over another remains more hypothesis than established fact.

An equally important limitation is that much of the available evidence reflects technologies that are no longer representative of contemporary practice. Structural heart disease evolves at a pace rarely encountered elsewhere in cardiovascular medicine. New transcatheter valve platforms, implantation techniques, commissural alignment strategies, leaflet modification procedures, coronary protection methods, and patient selection criteria continue to evolve while randomized trials require five to ten years to mature. Consequently, by the time long-term follow-up becomes available, the devices and procedural strategies studied often represent a previous generation of technology. Individual trials should be interpreted not as definitive answers but as snapshots of a particular technological era. This "moving target" phenomenon should temper both enthusiasm and criticism when applying historical data to contemporary clinical practice.

The same principle applies to surgical management. Registry data describing TAVR explant outcomes largely reflect the early experience of surgeons learning a new and technically demanding operation (2). Since those reports, surgical techniques for frame compression, safe prosthesis extraction, aortic reconstruction, and concomitant valve procedures have continued to evolve, along with a declining frequency of TAVR procedural failures requiring emergent TAVR explant (3). Consequently, historical mortality estimates may not accurately represent outcomes achievable today at experienced centers. Equally important, TAVR explant is rarely an isolated valve replacement. Many patients require complex concomitant procedures including aortic root enlargement or replacement, ascending or arch reconstruction, mitral valve surgery, coronary bypass grafting, or repair of structural complications created by the index transcatheter procedure (2). These operations differ fundamentally from routine redo valve surgery and require expertise extending well beyond conventional aortic valve replacement.

If TAVR explant becomes an accepted component of lifetime management, the major challenge may therefore no longer be whether surgery is feasible but where it should be performed. Similar to other complex cardiovascular conditions, regionalization of care should be considered. Concentrating failed TAVR cases at experienced multidisciplinary referral centers may improve outcomes while allowing less complex structural heart procedures to remain broadly available. Future lifetime management strategies should therefore incorporate not only the choice of index valve but also an established pathway for referral when complex surgical rescue becomes necessary.

Ultimately, lifetime management should be viewed as a dynamic rather than static concept. It should not be reduced to choosing between SAVR-first or TAVR-first, nor should it rely exclusively on evidence generated from earlier generations of technology. Instead, it requires continuous reassessment as both transcatheter therapies and surgical techniques evolve. The future challenge is not simply to accumulate longer follow-up but to develop treatment strategies capable of adapting to a field in which technology advances faster than the evidence itself. Within that evolving landscape, TAVR-first followed by elective TAVR explant at experienced centers should be recognized as an increasingly legitimate lifetime treatment strategy rather than merely a salvage option.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article did not undergo external peer review.

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0049/coif). S.F. serves as a consultant for Medtronic Inc, Edwards Lifesciences, Artivion, LeMaitre, LifeNet Health, and Terumo Corporation. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hamana T, Samanta A, Chahal D, et al. A looming wave of bioprosthetic transcatheter valve failure?-rethinking lifetime management and reintervention in aortic stenosis. J Vis Surg 2026;12:25. [Crossref] [PubMed]
2. Fukuhara S, Brescia AA, Deeb GM. Surgical Explantation of Transcatheter Aortic Bioprostheses: An Analysis From the Society of Thoracic Surgeons Database. Circulation 2020;142:2285-7. [Crossref] [PubMed]
3. Fukuhara S, Suzuki T, Deeb GM, et al. Clinical outcomes of TAVR explant stratified by original risk profile: insights from 110 TAVR explants. Ann Cardiothorac Surg 2025;14:122-30. [Crossref] [PubMed]