Transcatheter aortic valve implantation in patients with a small aortic annulus: performance of supra-, intra- and infra-annular transcatheter heart valves

Abstract

Background A small aortic annulus is associated with increased risk of prosthesis–patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI). Whether specific transcatheter heart valve (THV) designs yield superior hemodynamic performance in these small anatomies remains unclear. Methods Data from 8411 consecutive patients treated with TAVI from May 2012 to April 2019 at four German centers were retrospectively evaluated. A small aortic annulus was defined as multidetector computed tomography-derived annulus area < 400 mm2. TAVI was performed with a balloon-expanding intra-annular (Sapien-3, n = 288), self-expanding intra-annular (Portico, n = 110), self-expanding supra-annular (Evolut, n = 179 and Acurate-Neo, n = 428) and mechanically expanding infra-annular (Lotus, n = 64) THV according to local practice. PPM was defined as indexed effective orifice area ≤ 0.85cm2/m2. Results A small annulus was found in 1069 (12.7%) patients. PPM was detected in 38.3% overall with a higher prevalence after implantation of a balloon-expanding intra-annular or mechanically expanding infra-annular THV compared to self-expanding intra- and supra-annular THV. Multivariable analysis linked self-expanding THV (Evolut: Odds ratio [OR] 0.341, Acurate-Neo: OR 0.436, Portico: OR 0.291), postdilatation (OR 0.648) and age (OR 0.968) to lower rates of PPM, while aortic valve calcification was associated with an increased risk (OR 1.001). Paravalvular regurgitation > mild was more frequent after TAVI with self-expanding THV (p = 0.04). Conclusion In this large contemporary multicenter patient population, a substantial number of patients with a small aortic anatomy were left with PPM after TAVI. Self-expanding supra- and intra-annular THV demonstrated superior hemodynamics in these patients at risk, however at the cost of higher rates of residual paravalvular regurgitation. Graphic abstract

Prosthesis‐patient mismatch after transcatheter implantation of contemporary balloon‐expandable and self‐expandable valves in small aortic annuli

“…The fact that SAV implantation was the only independent predictor of severe PPM and that the multivariable predictor analysis of PPM including SAV performed better than that including SEV reinforce the concept that leaflet position in the subgroup of patients analyzed in the current study is key for forward hemodynamics after TAVI. Even though recent studies linked SEV implantation to lower incidence of PPM and better hemodynamics independently from leaflet position, 32 our results confirm previous evidence suggesting a benefit of this valve design in small aortic annuli 14,33,34 …”

Valve Hemodynamics by Valve Size and 1-Year Survival Following Implantation of the Portico Valve in the Multicenter CONFIDENCE Registry

“…The gradients were in the single-digit range even in patients with a very small annulus who had been treated with the 23-mm valve. 12 , 13 This finding is very remarkable for a valve with an intra-annular design and is rather comparable to supra-annular devices from a hemodynamic point of view. 14 Apart from that, the intra-annular design is usually associated with better accessibility of the coronary ostia.…”

Impact of aortic annular size and valve type on haemodynamics and clinical outcomes after transcatheter aortic valve implantation

“…Studies have shown that SEV have better valve haemodynamics and lower PPM rates than BEV. 29,30 Anatomically, the result of better haemodynamics may be driven by the supra-annular location in SEV compared with intra-annular location in BEV. 21 These findings were also seen in our study but primarily in the SAA group.…”