Outcomes and treatment strategy of transcatheter aortic valve replacement with balloon-expandable valve in borderline-size annulus

• Published in: Cardiovascular revascularization medicine Vol. 66; pp. 6 - 14
• Main Authors: Isogai, Toshiaki, Spilias, Nikolaos, Bakhtadze, Beka, Sabbak, Nabil, Denby, Kara J., Layoun, Habib, Agrawal, Ankit, Shekhar, Shashank, Yun, James J., Puri, Rishi, Harb, Serge C., Reed, Grant W., Krishnaswamy, Amar, Kapadia, Samir R.
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.09.2024
• Subjects: Aged; Aged, 80 and over; Aortic Valve - diagnostic imaging; Aortic Valve - physiopathology; Aortic Valve - surgery; Aortic Valve Stenosis - diagnostic imaging; Aortic Valve Stenosis - mortality; Aortic Valve Stenosis - physiopathology; Aortic Valve Stenosis - surgery; Balloon Valvuloplasty - adverse effects; Balloon-expandable valve; Borderline-size annulus; Female; Heart Valve Prosthesis; Hemodynamics; Humans; Male; Outcome; Postoperative Complications - etiology; Prosthesis Design; Recovery of Function; Retrospective Studies; Risk Assessment; Risk Factors; Time Factors; Transcatheter aortic valve replacement; Transcatheter Aortic Valve Replacement - adverse effects; Transcatheter Aortic Valve Replacement - instrumentation; Transcatheter Aortic Valve Replacement - mortality; Transcatheter heart valve size; Treatment Outcome; Borderline-size annulus; Transcatheter aortic valve replacement; Transcatheter heart valve size; Outcome; Balloon-expandable valve
• ISSN: 1553-8389; 1878-0938; 1878-0938
• DOI: 10.1016/j.carrev.2024.03.030

Candidates for transcatheter aortic valve replacement (TAVR) occasionally have a “borderline-size” aortic annulus between 2 transcatheter heart valve sizes, based on the manufacturer's sizing chart. Data on TAVR outcomes in such patients are limited. We retrospectively reviewed 1816 patients who underwent transfemoral-TAVR with balloon-expandable valve (BEV) at our institution between 2016 and 2020. We divided patients into borderline and non-borderline groups based on computed tomography-derived annular measurements and compared outcomes. Furthermore, we analyzed procedural characteristics and compared outcomes between the smaller- and larger-valve strategies in patients with borderline-size annulus. During a median follow-up of 23.3 months, there was no significant difference between the borderline (n = 310, 17.0 %) and non-borderline (n = 1506) groups in mortality (17.3 % vs. 19.5 %; hazard ratio [HR] = 0.86 [95% CI = 0.62–1.20], p = 0.39), major adverse cardiac/cerebrovascular events (MACCE: death/myocardial infarction/stroke, 21.2 % vs. 21.5 %; HR = 0.97 [0.71–1.32], p = 0.85), paravalvular leak (PVL: mild 21.8 % vs. 20.6 %, p = 0.81; moderate 0 % vs. 1.2 %; p = 0.37), or mean gradient (12.9 ± 5.8 vs. 12.6 ± 5.2 mmHg, p = 0.69) at 1 year. There was no significant difference between the larger-(n = 113) and smaller-valve(n = 197) subgroups in mortality (23.7 % vs. 15.2 %; HR = 1.57 [0.89–2.77], p = 0.12), MACCE (28.1 % vs. 18.4 %; HR = 1.52 [0.91–2.54], p = 0.11), mild PVL (13.3 % vs. 25.9 %; p = 0.12), or mean gradient (12.3 ± 4.5 vs. 13.6 ± 5.3 mmHg, p = 0.16); however, the rate of permanent pacemaker implantation (PPI) was higher in the larger-valve subgroup (15.9 % vs. 2.6 %, p < 0.001). Borderline-size annulus is not associated with higher risk of adverse outcomes after BEV-TAVR. However, the larger-valve strategy for borderline-size annulus is associated with higher PPI risk, suggesting a greater risk of injury to the conduction system. [Display omitted] •Patients undergoing TAVR may have an aortic annular size that falls in the grey zone between 2 prostheses sizes.•The presence of borderline-size annulus is not associated with worse outcomes after balloon-expandable TAVR.•In borderline annulus, valve size should be selected based on the individual anatomic patient characteristics.•Implantation of the larger THV in borderline annulus is associated with higher pacemaker risk.