Beyond the First Valve: A Longitudinal Framework for Aortic Valve Replacement Selection

The growing population of patients expected to outlive their index aortic valve replacement (AVR) demands a fundamental shift in treatment planning to one that treats the first valve as the opening commitment in a lifetime management sequence of aortic stenosis. In this review, we propose a longitudinal framework for AVR selection that integrates age, anticipated survival, valve durability, coronary access preservation, and prosthesis-patient mismatch into a unified approach-one that evaluates the index procedure not in isolation, but by the downstream options it preserves or forecloses.