Transcatheter Aortic Valve Replacement in Patients With Extra-Large Aortic Annuli: Insights From a Large Cohort

Patients with large or extra-large aortic annuli pose a particular challenge for Transcatheter aortic valve replacement (TAVR), as clinical outcomes are less favorable than in patients with smaller annuli. This study aimed to evaluate periprocedural and clinical outcomes in patients with large and extra-large annuli undergoing TAVR and to compare results between balloon-expandable (BEVs) and self-expanding valves (SEVs). This study included patients with severe aortic stenosis (AS) and extra-large annuli who underwent TAVR with either BEVs or SEVs. The primary endpoints were periprocedural and clinical outcomes, including device success, rates of moderate or greater paravalvular leak (PVL), permanent pacemaker (PPM) implantation, new Left bundle branch block (LBBB), stroke, and in-hospital and 1-year mortality. Secondary endpoints included safety outcomes and subgroup analyses comparing outcomes between patients with large (annular perimeter >90 mm and an area >660 mm²) and extra-large annuli (perimeter >96 mm and an area >730 mm²). A total of 237 patients underwent TAVR, including 160 with BEVs and 77 with SEVs. The mean annular area and perimeter were 737 ± 76 mm² and 96.1 ± 4.1 mm, respectively, with no significant differences between groups. Overall device success was high, though slightly lower in the SEV group (84% vs. 93%, p = 0.034), a difference that was no longer statistically significant after multivariate analysis (p = 0.234). Moderate or greater PVL occurred more frequently with SEVs (13% vs. 4%, p = 0.016), particularly in patients with extra-large annuli (26% vs. 4%, p = 0.012). One-year mortality was similar between groups (SEV 13% vs. BEV 12%, p = 0.807), and no significant differences were observed in PPM implantation, new LBBB, stroke, or major vascular and bleeding complications. TAVR is feasible and safe in patients with large and extra-large annuli, with higher rates of moderate or greater paravalvular leak observed in SEV patients with extra-large annuli.