Relationship between a small aortic annulus and clinical and quality-of-life outcomes in patients undergoing TAVR

Background A small aortic annulus is associated with impaired hemodynamics after transcatheter aortic valve replacement (TAVR). The impact on long-term clinical or patient-centered outcomes remains unclear. Aims To evaluate the association between aortic annulus size and long-term clinical outcomes and patient-reported health status after TAVR. Methods In this post-hoc analysis of the multicenter SCOPE I randomized trial, patients were categorized according to computed tomography–derived annular size (small ≤ 430 mm 2 , larger > 430 mm 2 ). Outcomes included clinical events, disease-specific health status assessed with the Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OS) and an integrated patient-centered outcome defined as being alive with good health status (KCCQ-OS ≥ 75 without a decline > 10 points from baseline). Results Among 732 patients, 323 (44.1%) had a small and 409 (55.9%) larger annulus. Patients with a small annulus were more frequently women and had slightly higher surgical risk. Despite higher transvalvular gradients and a higher prevalence of prosthesis–patient mismatch, patients with a small annulus had no differences in all-cause mortality (18.6% vs 25.4%), heart-failure hospitalization (14.9% vs 15.6%), or patient-reported health status at 3 years, and a comparable probability of being alive with good health status (46.5% vs 43.2%; OR 0.95, 95% CI 0.63–1.44, p = 0.81). In an exploratory factorial analysis, a small annulus treated with a balloon-expandable valve was associated with a lower probability of this integrated outcome (RR 0.59, 95% CI 0.41–0.85; p for interaction = 0.004). Conclusions Patients with small aortic annuli experience comparable long-term survival and quality-of-life recovery after TAVR. Exploratory analyses suggest that valve type may influence patient-centered outcomes in this population. Graphical Abstract Relationship between a Small Aortic Annulus and Clinical and Quality-of-Life Outcomes in Patients undergoing TAVR. Abbreviations: HR = Hazard Ratio, OR = odds ratio, PPM = prosthesis-patient mismatch; TAVR = transcatheter aortic valve replacement.