Transcatheter Aortic Valve Implantation in Patients with Large Annulus

Background: Sizing of the aortic annulus before transcatheter aortic valve implantation (TAVI) is a crucial part of pre-procedural assessment. When using CTA for sizing, current recommendations for sizing limit the use of TAVI for aortic annulus of 18-29 mm and 20.7-29.5 mm for the self-expanding and balloon-expandable valves, respectively. Inappropriate sizing may result in perivalvular leak (PVL) or annular rupture. We aimed to report our experience of TAVI in patients with large annulus exceeding current recommendations.

Methods: Six patients of 442 who underwent TAVI in our institute had mean aortic annulus diameter >=29mm per CTA. PVL was assessed hemodynimacally, angiographocally and by echocardiography, and was categorized into grades 0 to 4.

Results: Mean age of the study population was 75±13. All patients were males. Five patients underwent TAVI for severe aortic stenosis and 1 patient for severe aortic regurgitation. Patients were implanted with either Sapien-3 29 mm or Corevalve 31 mm (4 and 2, respectively). Immediate post-procedure assessment of PVL demonstrated no PVL in 3 patients, mild PVL in 2 patients, and mild-moderate PVL in 1 patient. By 1-day post-procedure echocardiography, 1 patient had no PVL, 3 had mild PVL, and 2 had mild-moderate PVL. Only 1 patient had complete atrio-ventricular block and received permanent pacemaker. No other major complications were noted. In the whole group of TAVI patients, logistic regression adjusted for age and gender did not find relation between large annulus diameter and PVL (OR=0.72, CI 0.08-6.57, p=0.77).

Conclusions: TAVI is feasible and safe in patients with large annulus, excessing current recommendations. When carefully selected, patients with large anatomy can also benefit from TAVI without significant PVL