Aortic stenosis is the most prevalent valvular heart disease requiring intervention, especially in the elderly population. Surgical aortic valve replacement and transcatheter aortic valve implantation (TAVI) are well established treatment options for symptomatic patients with severe aortic stenosis, as they provide a significant survival benefit. Aortic stenosis may have an important impact on patients’ quality of life (QoL). However, advanced age, comorbidities and frailty may limit the beneficial effect of aortic stenosis interventions in terms of QoL. Current guidelines mention the importance of frailty and avoiding the futility of interventions, but lack specific indications about decision-making. Also, there are limited data on how to specifically assess QoL in aortic stenosis patients since the most used questionnaires are validated in different populations (i.e. heart failure). The aim of this review is to summarize all the available tools for QoL assessment in patients with aortic stenosis; to report current evidence on the impact of TAVI on QoL; and to discuss the role of frailty and comorbidities in this setting.

Aim: To identify risk factors that may be associated with lack of improvement in quality of life (QoL) in patients undergoing transcatheter aortic valve implantation (TAVI). Methods: We analyzed data from 116 patients with severe aortic stenosis (AS) undergoing TAVI in a tertiary center. QoL was assessed using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) at baseline and then at 1–3 months (first follow-up with a bounded time frame), 6 months and 12 months after the procedure. The primary outcome was the MLHFQ score, with higher scores indicating worse QoL. Mixed-effects modeling was used to evaluate predictors of longitudinal changes in QoL. Results: The mean MLHFQ score improved significantly from 41.1 ± 16.6 at baseline to 23.4 ± 10 at 12 months (P < 0.001), indicating enhanced QoL post-TAVI. However, several variables were associated with worse QoL trajectories over time. These included peripheral artery disease (PAD), paravalvular leak (PVL) ≥ grade 2, contrast-induced nephropathy, moderate-to-severe tricuspid regurgitation, pulmonary hypertension (PH), elevated creatinine, lower hemoglobin, reduced left ventricular ejection fraction, and increased left atrial diameter. PAD and PVL were consistent predictors of impaired QoL both early and late after TAVI. Conclusion: TAVI significantly improves QoL in most patients with severe AS, but certain comorbidities and complications – particularly PAD, PVL, and PH are associated with suboptimal recovery. Identifying these risk factors may help guide individualized follow-up and supportive strategies to optimize patient-centered outcomes.

Transcatheter aortic valve implantation (TAVI) has become the preferred therapeutic option for patients with severe aortic stenosis (SAS) at high or intermediate surgical risk. Despite its minimally invasive nature, TAVI is frequently associated with post-procedural complications, among which acute kidney injury (AKI) represents a major clinical concern. Early identification of patients at increased risk for AKI remains a critical unmet need. This retrospective, observational, single-center study enrolled consecutive patients with severe aortic stenosis who underwent TAVI between December 2022 and December 2023. The primary endpoint was to identify independent predictors of acute kidney injury (AKI) within 48 hours after TAVI. Secondary endpoint was to identify independent predictors of hospitalization for heart failure (HHF) during follow-up. Predictive modeling was conducted using the eXtreme Gradient Boosting (XGBoost) algorithm, with interpretability enhanced via SHapley Additive exPlanations (SHAP). A total of 116 patients were included (mean age 76±6.5 years; 57% male). Comorbidities were common, including heart failure (41%), coronary artery disease (32%), atrial fibrillation (41%), diabetes mellitus (29%), and chronic kidney disease (34%). Median EuroSCORE II was 2.1 (IQR 1.5-3.9). Median ferritin was 99.5 ng/mL (IQR 40-129), mean hemoglobin 12.3±1.7 g/dL and mean eGFR was 69.9±24.9 mL/min/1.73 m². After TAVI procedure, AKI occurred in 9% of patients within 48 h. According to the SHAP analysis, ferritin and TSAT emerged as the two most influential features in AKI prediction. The machine learning model achieved high sensitivity (96%) and an F1-score of 0.98, suggesting strong clinical utility for early risk stratification. In patients undergoing TAVI, iron deficiency, as reflected by low ferritin and TSAT levels, emerged as independent predictors of early post-procedural AKI.

Hostile abdominal aortic anatomy may limit transfemoral transcatheter aortic valve implantation (TAVI), even when the iliofemoral access vessels are suitable. The principal anatomical substrate is advanced atherosclerotic calcification, which may cause luminal stenosis, reduced arterial compliance, and an increased risk of vascular injury or embolization during large-bore device passage. Evidence regarding endovascular access facilitation is derived predominantly from iliofemoral interventions, whereas experience with direct modification of the abdominal aorta remains limited. This review examines balloon angioplasty, intravascular lithotripsy, and other endovascular strategies used to facilitate transfemoral TAVI in hostile iliofemoral and aortic anatomy, complemented by an illustrative case highlighting the additional challenge posed by intraluminal foreign material. Within this context, we present a 75-year-old high-risk patient with symptomatic severe aortic stenosis and significant coronary artery disease, in whom otherwise suitable iliofemoral access was complicated by focal calcific abdominal aortic stenosis and an asymptomatic impacted fragment of a fractured superior mesenteric artery stent following a previous intervention. A staged strategy comprising coronary revascularization, abdominal aortic balloon angioplasty with apposition of the fragment against the aortic wall, and subsequent balloon-expandable TAVI was successfully performed. This case underscores the importance of individualized, imaging-guided planning for complex transfemoral access.

Transcatheter aortic valve implantation (TAVI) for pure native aortic regurgitation (AR) remains technically challenging, primarily because absent annular calcification limits prosthesis anchoring. We reviewed contemporary evidence on TAVI for native AR, focusing on devices, procedural performance, complications, and outcomes. A comprehensive PubMed search identified 371 articles, of which 28 studies comprising 3282 patients met the inclusion criteria; notably, 64.3% were published from 2023 onward, reflecting the rapidly expanding evidence in this field. Conventional off-label devices were evaluated in 60.7% of studies and dedicated AR devices in 35.7%, while 3.6% directly compared both strategies. Technical/device success ranged from 72% to 100%, generally exceeding 85–90% in contemporary series, while 30-day mortality ranged from 0% to 23%. To illustrate the technical challenges and expand this evidence, we present a 24-year-old man with MYH7-associated hypertrophic obstructive cardiomyopathy and severe post-myectomy AR complicated by biventricular failure, cardiogenic shock, and multiorgan dysfunction. Given prohibitive surgical risk, rescue transfemoral TAVI was performed. Despite embolization of the first balloon-expandable prosthesis, a second valve was successfully implanted using an individualized anchoring strategy. At 1 year, the patient was in NYHA class I with biventricular recovery. TAVI represents an evolving alternative for carefully selected patients with severe native AR and prohibitive surgical risk.