Procedural Strategies for Optimal Transcatheter Aortic Valve Replacement: an International Position Statement (JACC Cardiovascular Interventions July 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 article emphasizes that the goal is no longer just successful valve delivery, but durable valve performance, preserved coronary access, low gradients, and avoidance of permanent pacemaker implantation to support lifetime valve management.

A central concept is the TAVR CODE framework: <strong>coaxiality, orientation, depth, and expansion</strong>. These four fluoroscopic parameters are proposed as a standardized way to assess and improve transcatheter heart valve (THV) implantation during the procedure.

The document discusses practical strategies for each step:
- <strong>Predilatation</strong> may help delivery, positioning, and expansion, especially in calcified, bicuspid, or otherwise complex anatomy.
- <strong>Coaxiality</strong> is important because noncoaxial implantation is linked to more pacemakers, paravalvular leak, and worse outcomes.
- <strong>Orientation/commissural alignment</strong> is aimed mainly at preserving future coronary access and enabling redo-TAVR or leaflet modification.
- <strong>Correct implant depth</strong> helps reduce paravalvular regurgitation and conduction disturbances.
- <strong>Expansion</strong> should be assessed intraprocedurally, with postdilatation used selectively when underexpansion, leak, or residual gradient is present.

The article also explains that underexpansion may contribute to valve dysfunction through paravalvular regurgitation, prosthesis-patient mismatch, leaflet distortion, and leaflet thickening/thrombosis. However, aggressive optimization can also increase risks such as annular rupture, embolization, coronary compromise, and leaflet injury.

Much of the current guidance is based on expert consensus and retrospective/mechanistic data, but randomized trials are underway to test systematic pre- and postdilatation, double-tap techniques, and commissural alignment methods. The authors conclude that structured implementation of TAVR optimization strategies may improve both short- and long-term outcomes, though more prospective evidence is still needed.

Meta Tag

Concept TAVR CODE framework

Concept Transcatheter Aortic Valve Replacement

Concept Transcatheter Heart Valve

Concept Underexpansion

Concept Coaxiality

Keywords

TAVR

transcatheter aortic valve replacement

TAVR CODE

coaxiality

commissural alignment

implant depth

valve expansion

predilatation

postdilatation

coronary access

TAVR CODE framework

Transcatheter Aortic Valve Replacement

Transcatheter Heart Valve

Underexpansion

Coaxiality