As we approach 20 years of clinical experience with transcatheter aortic valve replacement (TAVR), a vast portfolio of high-quality clinical data has accumulated, confirming the safety and efficacy of TAVR across the entire spectrum of surgical risk. Although many aspects of this innovative therapy have been thoroughly studied, several challenges remain. As TAVR is expanding to include younger low-risk patients, with longer life expectancy, one major unsolved issue is represented by transcatheter heart valve (THV) durability, since robust THV durability data are currently limited to approximately 5–6 years. Additionally, steric interactions between THV components and coronary ostia may render coronary access particularly difficult, and thus personalized decisions regarding THV type and implanting techniques are of paramount importance to secure future coronary access. Since bicuspid aortic valve (BAV) stenosis may be associated with unfavorable anatomic factors, it has represented an exclusion criterion in major randomized TAVR trials. Albeit promising data are available from multicenter registries, results of specifically designed randomized trials are eagerly needed to inform use of TAVR for BAV stenosis. Although valve-in-valve (ViV) TAVR has emerged as an effective treatment option for degenerated aortic bioprostheses, ViV procedures are associated with specific risks, which mandated the development of specific techniques aimed at reducing the occurrence of periprocedural adverse events. Despite the transfemoral approach represents the access of choice for TAVR, a significant proportion of patients have significant peripheral artery disease and alternative vascular access routes have been increasingly evaluated with encouraging data regarding their safety and feasibility.

随着我们在经导管主动脉瓣置换术 (TAVR) 方面接近 20 年的临床经验，积累了大量高质量的临床数据，证实了 TAVR 在整个手术风险范围内的安全性和有效性。尽管已经对这种创新疗法的许多方面进行了深入研究，但仍然存在一些挑战。随着 TAVR 扩大到包括预期寿命更长的年轻低风险患者，一个主要未解决的问题是经导管心脏瓣膜 (THV) 的耐久性，因为可靠的 THV 耐久性数据目前仅限于大约 5-6 年。此外，THV 成分和冠状动脉口之间的空间相互作用可能使冠状动脉通路特别困难，因此，关于 THV 类型和植入技术的个性化决策对于确保未来的冠状动脉通路至关重要。由于二尖瓣主动脉瓣 (BAV) 狭窄可能与不利的解剖因素有关，因此它已成为主要随机 TAVR 试验的排除标准。尽管可以从多中心注册处获得有希望的数据，但迫切需要专门设计的随机试验的结果来告知使用 TAVR 治疗 BAV 狭窄。尽管瓣中瓣 (ViV) TAVR 已成为退化的主动脉生物假体的有效治疗选择，但 ViV 程序与特定风险相关，这要求开发旨在减少围手术期不良事件发生的特定技术。尽管经股入路是 TAVR 的首选途径，