What question did this study set out to answer?

This review aims to summarize the current evidence on TAVI performance in large and extra-large aortic annuli.

January 17, 2026Srce i krvni sudovi0 citationsOpen Access

Transcatheter aortic valve implantation in large and extra-large aortic annuli: Contemporary evidence and performance of third-generation devices

IIIgor Ivanov ITIgor Tomas MČMilenko Čanković

Key Result

Transcatheter aortic valve implantation in large and extra-large aortic annuli achieved procedural success rates of 94-98% with 30-day mortality of 1-3%.

Key Points

This review aims to summarize the current evidence on TAVI performance in large and extra-large aortic annuli.
Summarized anatomical definitions and procedural outcomes.
Reviewed hemodynamic performance of four major third-generation valve platforms.
Analyzed data from multicenter registries and dedicated cohorts for large annuli.
Large annuli defined as 500-683 mm²; XL annuli exceed 683 mm².
Procedural success rates ranged from 94-98%.
30-day mortality rates were recorded at 1-3%.
Stable hemodynamics achieved despite exceeding standard IFU limits.
Modern sealing technologies effectively reduce the risk of paravalvular leak.

Structured PICO

Is TAVI using third-generation devices feasible and safe in patients with large and extra-large aortic annuli?

Population

Patients with large (500-683 mm²) and extra-large (>683 mm² or perimeter >94 mm) aortic annuli undergoing transcatheter aortic valve implantation

Intervention

Transcatheter aortic valve implantation (TAVI) using third-generation platforms (Evolut 34 mm, SAPIEN 3 29 mm, Navitor TITAN 35 mm, and Myval XL)

Outcome

Procedural outcomes and hemodynamic performance (including procedural success, 30-day mortality, and paravalvular leak)

Third-generation TAVI devices demonstrate high procedural success (94-98%) and low 30-day mortality (1-3%) in patients with large and extra-large aortic annuli, extending the feasibility of TAVI to anatomies previously considered borderline or unsuitable.

Limitations

Lack of prospective comparative studies
Need for long-term durability data

Abstract

Background: Large and extra-large (XL) aortic annuli represent one of the most challenging anatomical subsets in contemporary transcatheter aortic valve implantation (TAVI), owing to dimensions exceeding Instructions for Use (IFU) limits, elliptical annular geometry, and heavy calcification. Recent expansion of device sizes and refinement of sealing systems in third-generation valves have enabled TAVI in anatomies previously considered borderline or unsuitable. Methods: This narrative review summarizes anatomical definitions, procedural outcomes, and hemodynamic performance of four major third-generation platforms-Evolut 34 mm, SAPIEN 3 29 mm, Navitor TITAN 35 mm, and Myval XL-based on multicenter registries and dedicated large-annulus cohorts. Results: Large annulus is typically defined as 500-683 mm², while XL annulus corresponds to 683 mm² or perimeter 94 mm. Across major databases procedural success ranged from 94-98%, with 30-day mortality 1-3% and stable hemodynamics despite annular dimensions beyond standard IFU ranges. Paravalvular leak (PVL) remains the primary challenge; however, modern sealing technologies (NaviSeal™, PET cuff, pericardial wrap) significantly mitigate this risk. Conclusion: Contemporary evidence shows that TAVI in large and XL annuli is feasible, safe, and associated with excellent early outcomes when supported by precise CT-guided planning and appropriate device selection. Future prospective comparative studies are warranted to refine device-specific indications and long-term durability in this anatomically demanding population.

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