Evidence on Valve Selection for Small Aortic Annuli in Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement in patients with small aortic annuli presents unique challenges related to prosthesis-patient mismatch, residual gradients, conduction disturbances, and lifetime valve management. Recent observational data have suggested potential differences in mid-term survival between self-expanding valve and balloon-expandable valve platforms; however, these findings have not been consistently supported by other observational studies or long-term randomized evidence. Importantly, both severe prosthesis-patient mismatch and permanent pacemaker implantation may carry prognostic implications, underscoring the competing risks involved in valve selection. In conclusion, current evidence does not establish the clinical superiority of one transcatheter valve platform over another, supporting an individualized approach to valve selection.