Predictors of haemodynamic performance in patients with aortic stenosis and small annulus undergoing TAVI with self-expandable valves

Abstract Background Small aortic annular size is one of the most important predictor of poor hemodynamic and clinical outcomes in patients treated for aortic stenosis. Post-hoc analyses of pivotal trials showed that transcatheter aortic valve intervention (TAVI) offer better outcomes then surgery in patients with small aortic annulus, especially with self-expandable valves (SEV). However, data about SEVs comparison in this population are limited. Purpose Our aim is to assess how valve design and oversizing, with anatomical and echographic features, impact on the hemodynamic performance of SEVs in TAVI patients with small aortic annulus. Methods The TAVI SMALL registry enrolled 859 patients with small aortic annulus (CT-scan annular perimeter≤72 mm or area ≤400 mm2) treated for aortic stenosis with currently available SEVs (Evolut R=397; Evolut PRO =84; Acurate Neo=140; Acurate TA= 61; Portico=177) at 9 European centers between 2011 and 2018. We performed multivariable backward logistic regression analyses to identify predictors of high postprocedural mean gradient, moderate-to-severe PPM, and moderate-to-severe para-valvular leak (PVL). Results After adjustment for LVEF, we identified annular perimeter and percentage of oversizing as independent predictors of lower post-procedural mean gradient. Implantation of intra-annular rather than supra-annular bioprosthesis was the only independent predictor of moderate-to-severe PPM. Predictors of moderate-to-severe PVL are reported in the Table. Conclusions Among patients with aortic stenosis and small aortic annulus treated with transcatheter SEVs, use of supra-annular bioproshtesis and oversizing were associated with improved valve performance. SEVs hemodynamic performance predictors Endpoint Variable Odds ratio 95% CI p-value Post-procedural mean gradient Left ventricular ejection fraction 1.06 1.02–1.10 0.006 Percentage of oversizing 0.97 0.94–0.99 0.049 Annular perimeter 0.87 0.76–0.99 0.035 Postdilation 0.50 0.19–1.27 0.144 Moderate to severe PPM Intra-annular vs. supra-annular bioprosthesis 1.26 1.03–1.53 0.023 Predilation 0.86 0.71–1.03 0.102 Moderate/severe annular calcification 0.85 0.71–1.03 0.096 More than mild PVL Moderate/severe annular calcification 0.87 0.76–0.99 0.045 Moderate/severe LVOT calcification 1.26 1.03–1.56 0.026 Predilation 1.10 0.99–1.22 0.086 CI indicates confidence interval; LVOT: left ventricular outflow tract; PPM: prosthesis-patient mismatch; PVL: para-valvular leak;. Funding Ackn