Self-expanding intraannular transcatheter heart valve in tapered LVOT morphology - impact on deployment precision and periprocedural aortic prosthesis migration

BACKGROUND: A tapered left ventricular outflow tract (LVOT) may influence outcomes in transcatheter aortic valve implantation (TAVI), especially regarding valve positioning and conduction disturbances. While this is established in cases of pure aortic regurgitation and stenosis with balloon-expandable valves, its effect in native high-grade aortic stenosis (AVS) using self-expandable (SE) valves remains unclear. This study evaluated the impact of tapered LVOT morphology on peri-procedural outcomes with a SE intraannular (IA) TAVI prosthesis. METHODS: Between June 2021 and April 2025, 354 patients with severe native AVS underwent TAVI using the SE IA TAVI prosthesis. Patients were stratified based on LVOT morphology (tapered vs. non-tapered). Clinical and hemodynamic outcomes, including incomplete periprocedural device migration (IPDM) and embolization, were compared between groups. RESULTS: Technical success (96.9% tapered vs. 97.8% non-tapered, p = 0.727) and device success (92.9% vs. 89.4%, p = 0.373) were similarly high. IPDM occurred significantly more often in patients with a tapered LVOT (18.9% vs. 6.6%, p = 0.001). Overall, rates of embolization (0.8% vs. 2.6%, p = 0.429) and Valve-in-Valve procedures (0.8% vs. 1.8%, p = 0.658) were rare. Multivariate logistic regression identified a tapered LVOT morphology (OR 2.47; 95% CI 1.26-4.87; p = 0.009) and severe aortic valve eccentricity (OR 2.16; 95% CI 1.03-4.57; p = 0.042) as independent predictors for IPDM and embolization. The rate of permanent pacemaker implantation was comparable (17.4% vs. 18.0%; p = 1.000). CONCLUSION: TAVI with the SE IA prosthesis demonstrated high procedural success across anatomical subgroups. However, a tapered LVOT was associated with a significantly increased risk of incomplete periprocedural device migration. In such cases, a slightly deeper implantation may enhance anchoring and stability. These findings highlight the critical importance of preprocedural anatomical assessment, particularly LVOT morphology, in optimizing outcomes for TAVI in native AVS.