Current Evidence, Emerging Evidence and Decision Making: An Algorithm for Leaflet Modification Procedures (JACC Cardiovascular Interventions June 2026)-Article: Procedural Strategies for Optimal Transcatheter Aortic Valve Replacement: an International Position Statement

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This international position statement reviews how to optimize transcatheter aortic valve replacement (TAVR) as the procedure expands to younger patients with longer life expectancy. The authors emphasize that the goals are not only procedural success, but also durable valve performance, preserved coronary access, reduced need for permanent pacemakers, and better lifetime management.

The paper introduces the <strong>TAVR CODE</strong> framework, which standardizes intraprocedural assessment using four fluoroscopic parameters: <strong>coaxiality, orientation, depth, and expansion</strong>. The statement is based on a modified Delphi process involving 27 experts from 27 centers in 13 countries, reflecting largely expert consensus because prospective evidence remains limited.

Key procedural strategies are discussed in detail:
- <strong>Predilatation</strong> may improve delivery, positioning, and expansion, especially in complex anatomy or when using self-expanding valves.
- <strong>Coaxiality</strong> is important for symmetric implantation; poor coaxiality is linked to pacemaker implantation, paravalvular leak, and worse outcomes.
- <strong>Orientation/commissural alignment</strong> helps preserve future coronary access and may facilitate redo-TAVR, though the hemodynamic impact remains uncertain.
- <strong>Implant depth</strong> strongly influences sealing, gradients, and conduction disturbance risk; optimal depth depends on valve type and anatomy.
- <strong>Expansion and postdilatation</strong> are crucial because underexpansion can cause paravalvular regurgitation, prosthesis-patient mismatch, leaflet pinwheeling, leaflet thickening, and valve deterioration.

The article also highlights emerging tools and technologies, including <strong>intravascular ultrasound</strong>, improved valve designs, rotational delivery systems, and <strong>artificial intelligence/robotic guidance</strong>. Ongoing trials are testing systematic pre- and postdilatation, same-volume “double-tap” balloon techniques, and commissural alignment strategies.

Overall, the statement argues that careful, standardized procedural optimization may improve TAVR durability and clinical outcomes, but more randomized and long-term data are needed.

Meta Tag

Concept TAVR CODE framework

Concept Transcatheter Aortic Valve Replacement

Concept Coaxiality

Concept Orientation

Concept Implant Depth

Keywords

TAVR

transcatheter aortic valve replacement

TAVR CODE

coaxiality

commissural alignment

implant depth

postdilatation

paravalvular leak

coronary access

valve durability

TAVR CODE framework

Transcatheter Aortic Valve Replacement

Coaxiality

Orientation

Implant Depth