Key result
Self-expanding valves match balloon-expandable valves for 1-year mortality but reduce prosthesis-patient mismatch.
Why the study?
A small aortic annulus presents hemodynamic challenges during TAVR, increasing the risk of prosthesis-patient mismatch and suboptimal valve performance.
Do self-expanding valves reduce mortality or improve hemodynamics compared to balloon-expandable valves in patients with a small aortic annulus undergoing TAVR?
Meta-Analysis (n=19,421)
Do self-expanding valves reduce mortality or improve hemodynamics compared to balloon-expandable valves in patients with a small aortic annulus undergoing TAVR?
Odds Ratio: 0.98 (95% CI 0.58–1.64)
p-value: p=0.93
In patients with a small aortic annulus undergoing TAVR, self-expanding valves offer superior hemodynamics and lower prosthesis-patient mismatch but higher risks of pacemaker implantation and paravalvular leak compared to balloon-expandable valves, with no difference in overall survival.
No survival difference permits flexible valve selection in small-annulus TAVR; extends evidence favoring self-expanding valves to minimize prosthesis-patient mismatch.
BACKGROUND: A small aortic annulus presents unique hemodynamic challenges during transcatheter aortic valve replacement (TAVR), increasing the risk of prosthesis-patient mismatch (PPM) and suboptimal valve performance. This study aimed to compare the efficacy and safety of self-expanding valves (SEVs) versus balloon-expandable valves (BEVs) in patients with a small aortic annulus. METHODS: A systematic search using 4 databases, including PubMed, Embase, Web of Science, and Cochrane CENTRAL, was conducted from inception to June 1, 2025. Studies comparing clinical outcomes of SEVs and BEVs in patients with a small aortic annulus were included. RESULTS: Thirty-eight studies involving 19,421 participants were included. No significant difference in all-cause mortality was observed between SEVs and BEVs from in-hospital to 5-year follow-up. SEVs were associated with a significantly lower risk of PPM at discharge (OR 0.34, 95 % CI 0.28-0.42), 30 days (OR 0.31, 95 % CI 0.21-0.47), and 1 year (OR 0.25, 95 % CI 0.15-0.42). However, SEVs were associated with a higher risk of in-hospital paravalvular leakage (PVL) (OR 1.95, 95 % CI 1.39-2.74), moderate-to-severe PVL (OR 2.48, 95 % CI 1.91-3.22), and permanent pacemaker implantation (PPI) both in-hospital and at 30 days. These findings remained consistent across sensitivity analyses limited to new-generation valves and propensity score-matched or randomized studies. CONCLUSIONS: SEVs offer favorable hemodynamic advantages and lower risks of PPM and valve dysfunction compared to BEVs, with no difference in survival. However, these benefits must be weighed against the increased risks of PVL and PPI. Individualized valve selection remains essential to optimizing outcomes in TAVR patients.
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Attachaipanich et al. (2025) conducted a meta-analysis in Severe aortic stenosis with a small aortic annulus (n=19,421). Self-expanding valves vs. Balloon-expandable valves was evaluated on 1-year all-cause mortality (OR 0.98, 95% CI 0.58-1.64, p=0.93). Self-expanding valves showed no significant difference in 1-year all-cause mortality compared to balloon-expandable valves (OR 0.98), but significantly reduced prosthesis-patient mismatch.
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