Optimizing TAVI strategy: balancing predilatation benefits and direct implantation efficiency.
This review argues for a selective, anatomy-driven approach to balloon aortic valvuloplasty during TAVI rather than routine predilatation, citing randomized trials, registries, and meta-analyses showing comparable device success and early clinical outcomes with direct implantation in favorable anatomy.
Predilatation retains a role in heavy leaflet calcification, bicuspid morphology, horizontal aorta, and difficult valve crossing, and may still help self-expanding platforms with lower opening force reduce paravalvular leak.
The review restates what has become de facto contemporary practice rather than breaking new ground, and no specific effect sizes are offered here to weigh procedural streamlining against embolic and expansion trade-offs.
Neither the ACC/AHA 2020 nor the ESC 2025 guidelines prescribe a predilatation strategy — this remains operator and platform judgment.
Balloon aortic valvuloplasty (BAV) has historically been considered an integral step during transcatheter aortic valve implantation (TAVI), facilitating valve crossing and expansion, particularly in early-generation devices. However, advances in valve technology, delivery systems, and imaging have prompted a shift toward direct TAVI without routine predilatation. Contemporary evidence from randomized trials, large registries, and meta-analyses demonstrates that direct TAVI is feasible and safe in anatomically favorable cases, with comparable device success and early clinical outcomes to BAV-assisted implantation. Nonetheless, predilatation remains valuable in selected patients with complex anatomy, including severe leaflet calcification, high transvalvular gradients, bicuspid morphology, horizontal aorta, or challenging valve crossing. Predilatation may further improve procedural control, optimize valve expansion, and reduce residual paravalvular leakage, particularly with self-expandable valves and platforms with lower intrinsic opening force. Conversely, routine BAV may increase procedural complexity, radiation and contrast exposure, and embolic risk. Overall, current evidence supports a selective, anatomy-driven approach to predilatation, balancing procedural efficiency with optimal valve deployment and safety. This review critically examines the evolving role of BAV in contemporary TAVI practice.
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