"All right. I'm Ole De Backer. I'm a structural interventional cardiologist from, Rieshospitalet, the Copenhagen University Hospital, working in Copenhagen in Denmark. And the topic today we're going to discuss is what, TAVR, the space or the position is of TAVR is in 2025.


Well, if we look what the TAVR landscape looks like and what we are, now and how we evolved over the past few years, I think that you can say that TAVR has now nearly become the first choice, therapy to treat patients with severe, symptomatic aortic stenosis. For sure, in the US in the US for nearly all ages above 60 years, TAVR is the first choice, treatment. In Europe, I think we're maybe still a little more conservative, mostly for patients above 75 years of age. But new, European guidelines, for treatment of patients with severe ATK stenosa are also on their way this summer. So many are anticipating also a lowering of the age, for sure to 70. So that's for sure something which we see as evolved, over the past few years.


Also, we see that at the hearty meetings, the real discussion of cervical risk is on itself, as is not that important any longer. I think it's, more we're discussing the anatomical suitability for transfemoral TAVI, and this determines that typically whether this patient will be treated with TAVI or not. And then two new, tendencies we've seen in 2025 is that the FDA approved now also TAVR, to treat asymptomatic severe aortic stenosis patients based on the EARLY TAVR Study. And we also see increasing rates of, redo TAVR, because we are treating younger patients with longer life expectancy with TAVR. So that's also normal that we see some of these patients back for redo TAVR, more and more.


Well, as TAVR has expanded to younger patients, I think there is more evidence needed and there definitely still some gaps of knowledge on, the performance of TAVR in bicuspid aortic stenosis. Currently, we have a mixed data. I would say some are positive, some are showing a little bit more, events for TAVR in bicuspid. But everything is mostly based on retrospective data. So we need more data on this, more robust data. And then we also need maybe, further optimization, of our TAVR procedures. We have seen a real trend the last decade of real simplification of our TAVR procedure, where we become really, very Minimalistic. We can do these procedures in local anesthesia with a minimum of insertion, lines etc, but maybe if we treat younger patients we have to maybe not go further simplify, but maybe look how can we further optimize. And that needs maybe more attention for commissure alignment, better valve expansion, based on some current trials like ACURATE IDE or some also data from UK TAVI or NOTION 2 trial. Maybe we can question ourselves. Are we good enough in getting an optimal TAVI implants these days?


Well, which valve technologies or procedural innovations show most promise? Well I think if you look to the valve itself, transcated heart valve technologies, I think there were still developments in devices with even smaller insertion profiles. Also valves which are increasingly better performing hemodynamically. So focus on better hemodynamic performance of these valves such as for example a dura VR valve which is nowadays in, in clinical trials being tested. There's new leaflet technologies with biomimetics, advanced leaflet design, so aiming all to restore, not only to alleviate and take away the aortic stenosis, but also to restore the native flow dynamics in the ascending aorta. And then maybe also some valves which can further reduce the pacemaker rates, be optimized even further the PVL rates, especially in bicuspid. So I think there's still room for further technological developments.


And as we're treating also younger patients with longer life expectancy, as I said mentioned earlier, there is also further optimization of these TAVR procedures with maybe more advanced intraprocessal imaging such as IVUS, vascular IVUS to see really expansion of valves, et cetera. So that's maybe also some new technology that could be integrated more in our TAVR workflow in the future. And then also maybe leaflet modification technologies as we will encounter more and more redo TAVR procedures then in these cases sometimes they require leaflet modifications. So there's many leaflet modification technologies being developed these days. Not all of them will hit the clinical, clinical practice. But it's going to be interesting to see which ones are really well functioning or not. And then the final maybe still the question will be if there's still room for or need for cerebral embolic protection. Nowadays it's almost kind of clinically dead I would say cerebral embolic protection after the negative trials or the sentinel device. But who knows what the future will bring. There for technologies.


Yeah, the optimal TAVR team and composition I think. Well if you look pure Objectively, how TAVR is being performed in 2025, I think we need operators with just especially good catheter skills. I mean, I know historically that this has been a hybrid procedure with sometimes surgeons involved in it as well. But if you look how a TAVR is performed these days, it's, it's basically a catheter driven procedure. And especially most of the programs worldwide are now also fully percutaneous programs. So I think the optimal TAVR composition, whether it's a cardiologist or a surgeon, it doesn't really matter, but it has to be a person or an operator who has real good, good catheter skills. And also in general, I would say if you're doing TAVR, but also more general structural, heart, interventions, you have to have a really good understanding of CT imaging, you have to have some skills of CT analysis, interpreting CT imaging analysis, or images at least. So this is also another skill, that has to be in your TAVR team.


Yeah. If we look to, if we really want to optimize patient outcomes for these patients with severe aortic stenosis, I think what we need or what we could do better is still that we do a better, first of all, better screening of these patients. There's still many patients which are left untreated. So better screening, a timely treatment of these patients with severe aortic stenosis, that's really important. We have to strive for the best possible, patient tailored treatment, whether it's surgery or tower. All these patients should be appropriately discussed at the heart team meeting. And then we need a proper preprocedural planning. I think we can also probably do better there in the next five to ten years. Maybe use of artificial intelligence, computational modeling, which surgical device, which tower device, is best as an index valve. I think also there we can maybe do better still. And we can have help from artificial intelligence.


Then if we look the TAVR procedure itself, maybe novel TAVR technologies resulting in even better valve performance is important. Also use of more advanced intra procedural imaging, to optimize TAVR outcomes both on the short and the long term. And then, even after the TAVR procedure, I think we can optimize our treatment of patients with severe aortic stenosis by looking what is the best, antithrombotic treatment. Do these patients need more than just a replacement of the aortic valve? The answer is very often yes. We are probably ignoring too much their left ventricular dysfunction, whether it's systolic or diastolic dysfunction. Should these patients sometimes get an SGLT2 inhibitor, yes or no? I think there's a lot of areas and space still for clinical investigations and clinical trials to investigate how we can further optimize these, patient outcomes. So this shows that treatment of these patients can still be drastically improved in the next five years? I believe so.”