Balloon-expandable versus self-expanding valves in severe aortic stenosis with small aortic annulus: an updated...

Balloon-expandable valve (BEV) and self-expanding valve (SEV) are used in transcatheter aortic valve replacement (TAVR). Patients with a small aortic annulus (SAA) make up to one-third of the cases and face higher risks of prosthesis-patient mismatch and high valvular gradients.

This meta-analysis aimed to compare balloon-expandable and self-expanding valves used in TAVR in patients with a SAA, focusing on hemodynamic and clinical outcomes.

We systematically searched Cochrane Central, PubMed, and EMBASE for studies comparing balloon-expandable and self-expanding valves in patients with SAA undergoing TAVR. Random effects models were applied to generate odds ratios (ORs) and mean differences with 95% confidence interval (CI).

Fifteen studies (two randomized controlled trials and 13 propensity-matched studies) with 5149 patients (48.4% balloon-expandable valves) were identified. BEVs were associated with a lower indexed effective orifice area (mean difference: -0.18, 95% CI: -0.25 to -0.10; P  < 0.00001) and higher transvalvular mean pressure gradient (mean difference: 4.32, 95% CI: 3.39-5.24; P  < 0.00001) and peak pressure gradients (mean difference: 4.87, 95% CI: 1.23-8.51; P  = 0.009). Permanent pacemaker implantation (OR: 0.57, 95% CI: 0.44-0.73; P  < 0.0001) and major bleeding (OR: 0.67, 95% CI: 0.47-0.96; P  = 0.03) were lower in balloon-expandable valves. BEVs increased the odds of any prosthesis-patient mismatch (OR: 2.28, 95% CI: 1.61-3.22; P  < 0.00001) and severe prosthesis-patient mismatch (OR: 3.16, 95% CI: 2.19-4.58; P  < 0.00001).

In patients with SAA undergoing TAVR, SEVs offer superior hemodynamic performance, whereas BEVs are associated with fewer conduction disturbances and bleeding events. Both valve platforms yielded similar clinical outcomes, underscoring the need for individualized device selection.