Long-term outcomes after balloon- or self-expandable transcatheter aortic valve replacement in small aortic annuli

Transcatheter aortic valve replacement (TAVR) is an established treatment for severe aortic stenosis. In patients with small aortic annuli (SAA), self-expandable valves (SEV) provide better hemodynamic performance than balloon-expandable valves (BEV); however, long-term outcomes remain unclear. We retrospectively analyzed 564 consecutive patients with SAA who underwent TAVR with follow-up of > 5 years, comparing BEV (n = 476) and SEV (n = 88). After propensity score (PS) matching, 84 patients were included in each group. Clinical outcomes were evaluated over a median follow-up of 2,134 days. Sensitivity analyses using inverse probability of treatment weighting were also performed. SEV was more frequently selected in patients with more severe baseline AS. SEV demonstrated more favorable post-procedural hemodynamics; BEV was associated with lower paravalvular leakage, whereas the difference in permanent pacemaker implantation was attenuated after PS matching. In the overall and propensity score-matched cohorts, there were no significant differences between BEV and SEV with respect to all-cause death, cardiovascular death, or first heart failure hospitalization. Moderate or greater hemodynamic valve deterioration incidence did not differ between groups in the overall (log-rank test, p = 0.372) or PS-matched cohort (log-rank test, p = 0.182). BVF events were rare in the overall cohort, and no BVF events occurred in the PS-matched cohort. SEV was associated with superior postprocedural hemodynamics; however, no significant differences in long-term clinical outcomes were observed compared with BEV. These findings underscore the need for further investigations using larger cohorts and contemporary devices to validate long-term comparative outcomes of BEV and SEV in patients with SAA.