Aortic Valve Intervention in Patients with Aortic Stenosis and Small Annulus

Over the last two decades, the management of aortic stenosis has undergone significant transformation due to developments in surgical techniques and the introduction of transcatheter aortic valve implantation (TAVI). These transformations have enabled improved patient selection and treatments to be tailored based on individual clinical and anatomical characteristics. Both surgical and transcatheter options have resulted in reduced mortality and enhanced quality of life for patients with aortic stenosis. Nonetheless, treating patients with small aortic annulus remains challenging despite advances in current technology. The insertion of a small prosthetic valve, leading to patient prosthetic mismatch, has been associated with heart failure hospitalization, early structural valve degeneration, and long-term mortality. Although aortic root enlargement was historically employed to address this issue, stentless and sutureless valves in the supra-annular position and, more recently, TAVI have emerged as alternative treatments for patients with small annulus and severe aortic stenosis. This review will provide an overview of the prevalence and anatomical characteristics of patients with aortic stenosis and small annulus. Additionally, we will discuss current treatment options, including surgery and TAVI, used to mitigate procedural and long-term adverse outcomes in this group.