Key result
In small annuli, supra-annular valves cut permanent pacemaker implants ~25% and improve 5-year survival vs intra-annular valves.
Why the study?
TAVR with self-expanding valves may have different outcomes depending on whether supra-annular or intra-annular valves are used in patients with a small aortic annulus.
Does the use of supra-annular self-expanding valves improve clinical and hemodynamic outcomes compared to intra-annular self-expanding valves in patients with a small aortic annulus undergoing TAVR?
Does the use of supra-annular self-expanding valves improve clinical and hemodynamic outcomes compared to intra-annular self-expanding valves in patients with a small aortic annulus undergoing TAVR?
In patients with a small aortic annulus undergoing TAVR, supra-annular self-expanding valves may offer better long-term survival and lower pacemaker implantation rates compared to intra-annular valves.
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Supports preferring supra-annular over intra-annular self-expanding valves in small-annulus TAVR to lower pacemaker risk and improve survival; extends prior evidence with pooled 5-year data.
Objective Transcatheter aortic valve replacement (TAVR) with self-expanding valves (SEVs) may have different outcomes with supra-annular valves (SAVs) or intra-annular valves (IAVs) in patients with a small aortic annulus (SAA). We aimed to evaluate different SEVs, namely SAVs (CoreValve/Evolut R/PRO/PRO+/FX) versus IAVs (Portico/Navitor). Methods Systematic review and meta-analysis of studies (published until September 2025) comparing SEV-SAV versus SEV-IAV in patients with SAA. Meta-analyses were conducted to assess early outcomes and mortality in the follow-up. Results Five observational studies met our eligibility criteria, including 3303 patients (SAV: 2295; IAV: 1008). We did not find statistically significant differences for 30-day mortality, stroke, acute kidney injury, coronary occlusion, major bleeding, and paravalvular leak; however, we found lower rates of permanent pacemaker implantation in the SAV group (RR 0.75; 95%CI 0.60-0.94; P = .013). Despite slightly larger effective orifice area (mean difference +0.05 cm 2 /m 2 ; 95%CI 0.01-0.10; P = .038), higher indexed effective orifice area (mean difference +0.07 cm 2 /m 2 ; 95%CI 0.01-0.12; P = .012) and slightly lower mean gradients (−0.91 mm Hg; 95%CI −1.77 to −0.05; P = .038) with SAVs, we did not find statistically significant differences in terms of residual mean gradients ≥20 mm Hg (RR 1.65; 95%CI 0.73-3.74; P = .232); however, SAV showed a lower risk of prosthesis-patient mismatch (RR 0.64; 95%CI 0.42-0.98; P = .042). We observed a statistically significant difference in survival at 5 years in favor of the SEV-SAV group (HR 0.770; 95%CI 0.600-0.980; P = .034). Conclusions IAVs and SAVs may have a different performance in terms of hemodynamic structural and nonstructural dysfunction in patients with SAA, which should be confirmed by randomized studies.
Sá et al. (2026) studied this question. Supra-annular valves in small aortic annulus patients reduced permanent pacemaker implantation by 25% (RR 0.75) and improved 5-year survival (HR 0.77) versus intra-annular valves.
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