Evolution of Transcatheter Aortic Valve Implantation over 12 Years: A Single High-Volume Center Perspective

Background: Transcatheter aortic valve implantation (TAVI) has transitioned from a therapy for inoperable or extreme-risk patients to a standard option across broader risk categories. How this evolution has reshaped patient selection, procedural practice, and early outcomes within a mature program over extended time remains incompletely described. Methods: We conducted a single-center retrospective observational cohort study including all consecutive patients undergoing TAVI for severe symptomatic aortic stenosis between 2012 and 2024. Patients were stratified into three temporal eras (2012–2015, 2016–2020, 2021–2024). Baseline clinical, imaging, and procedural variables were prospectively recorded. The primary endpoint was 1-month major adverse events (MAE), defined as a composite of all-cause death, stroke, myocardial infarction, major vascular complications, or major bleeding. Comparisons across eras used ANOVA and chi-square or Fisher exact tests, as appropriate; multivariable logistic regression was applied to identify independent predictors of MAE. Results: A total of 1,946 patients were included (n=230, 396, and 1,320 across the three eras). Mean age (~81 years) and sex distribution (~60% women) remained stable, whereas cardiovascular risk factors became more prevalent over time (dyslipidemia 46.4% to 89.9%, hypertension 90.9% to 97.7%, smoking 1.1% to 11.2%; all p<0.001). Functional status improved (NYHA III–IV 78.2% to 18.0%; p<0.001), and EuroSCORE II decreased (5.7±5.1 to 3.2±3.6; p<0.001). Angiographically significant coronary artery disease and bicuspid valves were more frequently treated in the most recent era. Transfemoral access under local anesthesia remained predominant, while fluoroscopy time, contrast volume, and procedural duration significantly decreased (all p≤0.003). Residual aortic regurgitation ≥moderate became rare, with none/trace regurgitation increasing from 57.8% to 91.3% (p<0.001). Hospital stay shortened (7.3±2.8 to 6.1±3.1 days; p<0.001). MAE declined from 17.4% to 7.2% (p<0.001), driven by marked reductions in major bleeding (10.0% to 0.7%; p<0.001) and stroke (2.6% to 0.3%; p=0.002), while 1-month mortality remained low (2.6% to 1.0%; p=0.087). The need for new permanent pacemaker implantation was frequent but stable (~17–19%; p=0.645). Conclusions: Over 12 years, this high-volume TAVI program has progressively shifted towards patients with more conventional cardiovascular risk profiles, lower surgical risk, and more complex coronary and valvular anatomy, while achieving shorter, more efficient procedures and improved early safety. These findings support the robustness of a structured Heart Team approach and underscore the importance of continuous optimization of TAVI pathways in an evolving and increasingly heterogeneous patient population.