Lost in Acronyms: A Missed Opportunity in the Early Days of TAVI Terminology

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“Stat rosa pristina nomine, nomina nuda tenemus” “The rose of old remains only in its name; we possess naked names” Umberto Eco, in “The Name of the Rose” In 2011, we submitted to a leading international journal of cardiac surgery a letter raising what we believed was an important conceptual issue: the correct terminology for the then-emerging field of transcatheter aortic valve procedures (Figure 1). At that time, we argued that the term “implantation” was more accurate than “replacement,” since in transcatheter procedures the diseased valve is not excised but left in place, and that “transcatheter” was preferable to “percutaneous,” as many procedures were (and still remain) performed through surgical cut-downs or alternative access routes. My call was for a clear, standardized nomenclature that would facilitate scientific communication and prevent semantic confusion. That letter was declined. Screenshot of the Original Manuscript Submitted in September 2011 to a Leading International Journal of Cardiac Surgery, in Which the Issue of Correct Terminology for Transcatheter Aortic Valve Procedures was First Raised Fourteen years later, in 2025, Indolfi, Esposito, and Lüscher published in the European Heart Journal a viewpoint that raised exactly the same semantic and conceptual points.1 Their contribution is timely and valuable, but it also highlighted a missed opportunity. Had the surgical and cardiology communities adopted a consensus earlier, much of the confusion that has since permeated publications, registries, and databases could have been avoided. This is not merely a matter of pride or semantics: terminology is a fundamental tool of science. It shapes how we classify, search, and interpret evidence, and how future generations understand and build upon our work. The most emblematic example is the persistent confusion between the acronyms TAVI (Transcatheter Aortic Valve Implantation) and TAVR (Transcatheter Aortic Valve Replacement). While the terms are often used interchangeably in the literature, only the former is accurate. In TAVI, the calcified valve remains in place and the prosthesis is deployed inside it: nothing is actually “replaced.” The word replacement suggests an excision, as in conventional surgical aortic valve replacement (AVR), and therefore introduces a conceptual inaccuracy. The widespread adoption of TAVR, used for the first time in 2007 by Lange R. has been driven largely by cardiology societies and by the medical device industry.2 In part, this choice may have been motivated by political or economic considerations, and in part by a lack of awareness of the precise surgical meaning of “replacement.” Whatever the reason, the effect has been to establish an incorrect term into the scientific discourse, where it continues to generate misunderstanding. The only future scenario in which “replacement” might be justified would be if technology 1 day allows for true transcatheter excision of calcified cusps prior to prosthesis implantation. In fact, we performed and published a proof-of-concept study on such a technique in an animal model in 2009.3 But unless the transcatheter valve implantation is preceded by removal of the native diseased cusps, the term implantation must be utilized instead of replacement. Some authors argue that TAVR is acceptable because the procedure replaces the function of the diseased valve; however, no function is actually removed or replaced. Rather, the physiological function of the native valve is restored, not substituted—reinforcing that implantation, not replacement, remains the correct term. The confusion created by the adoption of TAVR has even extended into surgical vocabulary. For decades, surgeons consistently used AVR to describe aortic valve replacement. The redundant term SAVR (Surgical Aortic Valve Replacement) only appeared after TAVR was introduced—specifically in 2010, when it was first used by Clavel et al—as an artificial linguistic counterpart.4 The introduction of the acronym “SAVR” is itself emblematic of how the surgical standard was reframed as if it were a derivative, rather than the reference therapy—a conceptual inversion that reflects the broader semantic distortion introduced by the misuse of “replacement” in transcatheter terminology. Yet SAVR makes no sense: there is no ambiguity in AVR, which for decades has referred to the surgical procedure, and there will never be a need to distinguish it from a hypothetical TAVR because, as explained, “replacement” is still only possible surgically. Moreover, SAVR is cacophonic, unnecessary, and semantically flawed. AVR is the correct and sufficient definition for the surgical procedure, and it should continue to be used exclusively. If and when true transcatheter excision of calcified leaflets becomes possible, then the term TAVR could be introduced legitimately. Until then, AVR and TAVI remain the only correct expressions, and SAVR has no reason to exist, neither now nor in the future. Today, the semantic challenge is growing even more complex, as we face an increasing number of reintervention scenarios. To date, the following acronyms have gained acceptance: Valve-in-Valve (ViV), describing a TAVI implanted inside a prior surgical bioprosthesis; TAVI-in-TAVI (TiT), indicating a TAVI implanted inside a prior TAVI; Valve-in-Valve-in-TAVI (ViViT), referring to a TAVI implanted inside a TAVI that itself had been implanted in a surgical bioprosthesis; and TAVI-in-TAVI-in-TAVI (TiTiT), meaning 3 successive TAVIs 1 inside the other. These acronyms, unlike TAVR, are conceptually correct. Valve-in-Valve may not be the most elegant formulation, but it is not incorrect: it conveys clearly that 1 valve is implanted within another. From the very beginning, it has been adopted by the community and has gained universal recognition.5 Importantly, the ViV (and derivative) nomenclature is not limited to the aortic valve. It should apply to all valve positions—mitral, tricuspid, pulmonary—as the logic is identical. Thus, ViV and its variations can serve as universal templates for describing reinterventions in transcatheter valve therapy. As the field expands beyond the aortic valve, we must be vigilant not to repeat the mistakes of the past. In the mitral space, many now use the term TMVR (Transcatheter Mitral Valve Replacement). This is as misleading as TAVR. Again, the native valve is not excised but left in place, meaning that the procedure is an implantation, not a replacement. The correct acronym is therefore TMVI (Transcatheter Mitral Valve Implantation). The same applies to the tricuspid position: TTVR should be abandoned in favour of TTVI (Transcatheter Tricuspid Valve Implantation). Only with these definitions do we preserve consistency across valve positions, avoid semantic inaccuracies, and align with the underlying surgical logic. Reintervention scenarios on the mitral and tricuspid valves should follow the same scheme as for the aortic valve: ViV, Valve-in-Ring, Valve-in-MAC, and potentially Valve-in-Valve-in-Valve configurations. By adopting this coherent and systematic terminology now, we can prevent another decade of confusion. It is worth emphasizing why surgeons should play a central role in defining terminology in this field. Surgeons are uniquely positioned because they perform the entire spectrum of interventions: conventional AVR and mini-AVR, transcatheter TAVI through all accesses routes, mitral and tricuspid replacements and repairs, both surgical and transcatheter. Only with this comprehensive perspective can we appreciate the precise meaning of terms like “replacement” versus “implantation.” Beyond semantics, the surgeon’s role is also crucial from a therapeutic perspective. Cardiac surgeons, having performed AVR for more than 70 years, possess the deepest understanding of valve anatomy, pathology, and the entire spectrum of operative strategies. Unlike other specialists, surgeons are able to offer patients all possible o

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