Outcomes of Patients With a Small and Large Aortic Annulus Following Balloon-Expandable Transcatheter Aortic Valve Replacement Across Flow-Gradient Patterns

Abstract

Background

Patients with small annuli are at risk for worse hemodynamic performance after transcatheter aortic valve replacement (TAVR). It is debatable whether a small annulus confers worse outcomes. This study explored the clinical outcomes following TAVR for patients with small and large annuli across flow-gradient subgroups of aortic stenosis (AS).

Methods

This is a retrospective cohort of patients >18 years who underwent TAVR at Cleveland Clinic between 2016 and 2020. Patients were classified into 2 groups according to annular size: small (area ≤430 mm²) and large (area >430 mm²). Patients undergoing TAVR with self-expanding valves and those with annular sizing using transesophageal echocardiography were excluded. Each group was subclassified into classical low-flow low-gradient (LFLG) AS, paradoxical LFLG AS, normal-flow low-gradient AS, and high-gradient AS. Clinical outcomes included mortality and heart failure rehospitalization.

Results

The study included 1866 patients, of which 709 (38%) had small annuli. There was no difference in heart failure rehospitalization and mortality between the groups in any of the 4 flow-gradient patterns: hazard ratio (HR) ​= ​0.93 (95% confidence interval [CI]: 0.51-1.69) for patients with classical LFLG AS, HR ​= ​0.95, CI (0.62-1.47) for patients with paradoxical LFLG AS, HR = ​1.16, CI (0.49-2.74) for patients with normal-flow low-gradient AS, and HR = ​0.73, CI (0.50-1.07) for patients with high-gradient AS, using large annulus as a reference. Patients with small annuli had higher mean gradients, lower dimensionless valve index, and a higher incidence of hypoattenuated leaflet thickening and structural valve deterioration post-TAVR.

Conclusions

Patients with small and large annuli have similar intermediate-term clinical outcomes post-TAVR across all flow-gradient patterns treated with balloon-expandable valve.