Device selection in patients with borderline size aortic valve annulus undergoing transcatheter aortic valve implantation - The 67th Annual Conference of the Israel Heart Society

Yeela Talmor-Barkan ¹ Ran Kornowski ¹ Hanna Vaknin-Assa ¹ Ashraf Hamdan ¹ Israel M Barbash ² Haim Danenberg ³ Maayan Konigstein ⁴ Noam Bar ⁵ Alon Barsheshet ¹ Pablo Codner ¹

¹Cardiology, Rabin Medical Center, Petach Tikva; Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Israel
²Leviev Heart Center, Chaim Sheba Medical Center, Ramat Gan; Affiliated to Sackler School of Medicine, Tel Aviv University, Israel
³Cardiology, Hadassah Medical Center, Jerusalem; Affiliated to the Hebrew University of Jerusalem, Israel
⁴Cardiology, Tel Aviv Sourasky Medical Center, Israel; Affiliated to Sackler School of Medicine, Tel Aviv University, Israel
⁵Computer Science and Applied Mathematics, Weizmann Institute of Science, Rehovot, Israel

Introduction: Proper transcatheter heart valve (THV) selection for transcatheter aortic valve implantation (TAVI) is crucial to achieve procedural success. Borderline aortic annulus size (BAAS) is a common challenge during device selection and the most effective THV selection strategy for these patients remains unclear. Herein, we aim to evaluate the outcomes of TAVI in patients with BAAS according to THV size selection.

Methods: We performed a retrospective study including patients with severe aortic stenosis (AS) and BAAS, measured by multidetector computed tomography (MDCT), undergoing TAVI with self-expandable (SE)/balloon-expandable (BE) THV from the Israeli multicenter TAVI registry. BAAS was defined based on THV manufacturer sizing instructions; size cut-off±1mm for SE-THV and borderline range for BE-THV. TAVI outcomes were assessed according to the Valve Academic Research Consortium-2.

Results: Out of 1,166 patients with proper MDCT measurements, 539 patients (46%) had BAAS as defined for at least one THV type (SE/BE). In BAAS patients treated with SE-THV, large THV selection was associated with significantly lower rate of paravalvular leak (PVL), as compared with small THV (no PVL 34.0 vs. 41.8%; mild PVL 60.0 vs. 38.1%; mild-moderate PVL 4.3 vs. 18%; moderate PVL 0% vs. 1.8%;p<0.05). In BAAS patients implanted with BE-THV no significant difference in PVL was noted between large and small THV selection. However, large BE-THV selection was associated with lower post-procedural transvalvular gradients compared to small THV (peak 17±7mmHg vs. 22±6.6mmHg; mean 9.9±3.9mmHg vs. 12.1±1mmHg;p<0.05). Of note, mortality, rate of new pacemaker implantation, stroke/transient ischemic attack, annular rupture and coronary occlusion did not differ between groups.

Conclusion: BAAS is highly common among patients undergoing TAVI. Selection of large rather than small THV in these patients is associated with lower rates of significant PVL and better hemodynamic profile in patients implanted with SE and BE-THV, respectively, with no effect on procedural complications.