Index transcatheter aortic valve replacement (TAVR) procedures must preserve coronary access, enable predictable redo-TAVR and optimize durability as the therapy expands to younger patients, a new viewpoint argues. The perspective, published online Monday and in the Feb. 23 issue of JACC: Cardiovascular Interventions, addresses which implantation characteristics can and cannot be optimized during balloon-expandable TAVR to improve long-term outcomes. Led by Julius Jelisejevas, MD, and colleagues, from St. Paul's and Vancouver General Hospital, Vancouver, British Columbia, the team noted that as TAVR expands into younger populations, operators must adopt a lifelong management mindset, not just focus on short-term procedural metrics. "As TAVR is offered to younger patients, the emphasis should shift from minimizing pacemaker risk alone to achieving a repeatable index procedure," they wrote, noting that higher implantation is associated with reduced feasibility of redo-TAVR. “The index TAVR must preserve coronary access, enable predictable redo-TAVR, and optimize durability,” authors wrote. “This shifts the focus on what can, and cannot, be optimized at the index procedure with an intraannular balloon-expandable (BE) TAVR to potentially improve outcomes.” Addressable targets Techniques targeting shallow implantation can reduce conduction disturbances and permanent pacemaker rates. However, higher implantation may elevate the transcatheter heart valve stent frame outflow plane above the left main coronary ostium plane, potentially compromising coronary access or redo-TAVR feasibility. Jelisejevas and colleagues noted that a recently validated left main view fluoroscopic projection for balloon-expandable TAVR complements 3-cusp and cusp-overlap approaches and specifically addresses the relationship between the valve outflow plane and the left main coronary ostium. This anatomy-aware projection reframes implantation height as a bidirectional decision that accounts for inflow-conduction trade-offs and outflow-coronary constraints at the index procedure, they said. Meanwhile, several geometric variables are addressable during index TAVR, including implantation depth and height and valve stent frame expansion, deformation and eccentricity, the team added. Incomplete stent frame expansion, deformation, eccentricity, asymmetrical expansion and noncoaxial deployment have all been associated with higher rates of early structural valve deterioration, they said. The Double-Tap study indicates that routine postdilatation using the same delivery balloon at deployment volume can significantly improve valve stent frame expansion across all levels without additional safety concerns, the investigators reported. The technique also reduces deformation and eccentricity across all valve sizes. Preliminary hydrodynamic testing data indicate reduced acute elastic recoil and less leaflet pinwheeling versus single inflation, according to the authors. These findings suggest that a simple postdilatation step at deployment volume may optimize balloon-expandable valve stent frame geometry and potentially reduce early or late structural valve deterioration. The coaxiality gap In contrast, coaxiality remains an unsolved intraprocedural variable, Jelisejevas and colleagues suggested. Beyond early recapture and repositioning on self-expanding platforms that allow it, there is no validated method to convert a fully released, noncoaxial frame into a coaxial one. It remains uncertain whether noncoaxiality directly causes premature structural valve deterioration or primarily marks adverse anatomy and device-tissue interaction that predispose to off-axis seating and inadequate expansion, they said. Valve stent frame noncoaxiality remains an important observation that highlights a gap without a solution to prevent it, according to the investigators. A reliable, reproducible method to achieve commissural alignment with current-generation intra-annular balloon-expandable valves is not yet available, with next-generation platforms expected to address this limitation. Index-TAVR optimization involves anatomy-guided platform selection and projection choice that favor precise deployment depth and height, implementation of techniques that optimize valve stent frame expansion and minimize deformation and eccentricity, and standardized documentation of final stent frame expansion, geometry and outflow plane relation to left main ostium, Jelisejevas and colleagues suggested. Adopting the left main view projection in selected patients, followed by valve stent frame optimization with routine postdilatation at deployment volume, represents a simple and potentially safe pathway to enhance geometry, preserve coronary access and facilitate redo-TAVR strategies, they said. Conversely, valve stent frame coaxiality remains an important observation that highlights a gap, the investigators noted. Depth and height, expansion, deformation and eccentricity are addressable to varying degrees during the index procedure, but coaxiality is not yet directly correctable. Source: Jelisejevas J, Husain A, Cook R, et al. Redo-TAVR begins at the index procedure: what can—and cannot—be optimized? JACC Cardiovasc Interv. 2026;19(4):525-528. Image Credit: Studio Romantic – stock.adobe.com