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%.
Is TAVI using third-generation devices feasible and safe in patients with large and extra-large aortic annuli?
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.
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.
Ivanov et al. (2025) studied this question. 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%.