How to avoid transcatheter aortic valve replacement explant as the second valve procedure: image assessment for the index transcatheter aortic valve replacement.

The management of severe aortic stenosis (AS) has evolved significantly, with a shift toward shared decision-making regarding the choice of transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). This shift necessitates careful consideration of long-term valve durability, as both TAVR and SAVR with bioprosthetic valves offer limited durability, potentially requiring reoperation later in life. While mechanical valves and the Ross procedure offer lifelong durability, patient preferences, including avoidance of anticoagulation, often dominate the discussion. This manuscript reviews the complex decision-making process in selecting the most appropriate valve for the first intervention, focusing on balancing the immediate benefits of a less invasive procedure with the long-term risks and the potential need for a second valve intervention. In the TAVR era, younger patients elect the least invasive treatment option with the shortest recovery. Age, anticoagulation tolerance, comorbidities, and aortic root anatomy influence valve choice, with particular attention to prosthesis-patient mismatch (PPM). Here, we emphasize that careful preoperative planning is essential to minimize PPM and optimize hemodynamics for the first valve, considering the possibility of future valve interventions. Furthermore, advanced imaging and simulation tools, such as computed tomography (CT) and artificial intelligence-based platforms, are now being utilized to predict the feasibility of redo interventions and guide the selection of the initial valve. The increasing prevalence of redo-TAVR and TAVR explantation underscores the importance of planning for a second valve at the time of the initial intervention. Simulation techniques can predict the anatomical feasibility of redo-TAVR, providing a safer framework for managing patients requiring subsequent valve replacements. Ultimately, heart teams must equip themselves with the tools and expertise necessary to ensure the durability of the first valve and readiness for future interventions, thereby improving patient outcomes over their lifetimes.