Tailoring Transcatheter Aortic Valve Implantation: Valve Selection, Coronary Management, and Patient-Specific Strategies Across Diverse Populations

Abstract

Background: Transcatheter aortic valve implantation (TAVI) is increasingly used in broader patient populations, where features such as bicuspid valves, small annuli, and concomitant coronary artery disease (CAD) present important anatomical and procedural challenges. This thesis evaluates how valve type, anatomical complexity, and CAD management influence contemporary TAVI outcomes. Methods: Five nationwide, registry-based studies were performed. Study I assessed the frequency and predictors of post-TAVI coronary angiography and the impact of valve design on future coronary access. Study II compared supra- versus intra-annular self-expanding valves (SEVs) in small annuli. Study III examined outcomes in bicuspid versus tricuspid stenosis. Study IV compared balloon-expandable valves (BEV) and SEV in bicuspid anatomy. Study V evaluated pre-TAVI PCI versus conservative management in patients with significant CAD. Results: Post-TAVI coronary angiography was uncommon, but younger age, periph-eral vascular disease, prior CAD, and prior PCI were associated with a higher risk. Coronary access was more technically challenging after SEVs. In small annuli, Evolut valves produced lower gradients but without demonstrating a clear clinical advantage. Bicuspid anatomy showed similar mortality to tricuspid cases but higher pacemaker requirements and lower device success. Within bicuspid anatomy, SEVs offered better hemodynamic performance but at the cost of increased paravalvular leak compared with BEVs. Pre-TAVI PCI did not improve survival or major cardiovascular outcomes compared to conservative management, though it reduced later elective revascularizat-ion at the expense of higher bleeding rates. Conclusions: As TAVI expands into more complex patient groups, procedures must be tailored to each individual and planned with a lifetime management perspective. Valve choice should reflect anatomical constraints and future coronary access needs, while pre-TAVI PCI should be reserved for clear indications. Optimal outcomes hinge on integrating anatomy, valve design, and coronary strategy within an individualized approach.