Small Aortic Annulus: What Valve Should We choose?

Courtesy of Dr. Carlos Fava

Surgical aortic valve replacement in a small annulus (<400 mm²) is associated with shorter duration, higher valve deterioration and patient prosthesis mismatch (PPM). They present a negative impact as regards duration and evolution.

TAVR might be an option, with superior hemodynamic outcome and lower PPM.

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A retrospective analyzis was carried out in 5 centers in Germany that included 246 patients with a small annulus. 129 of these patients received the ACCURATE neo S, and 117 the SAPIENS 3 23.

Characteristics were similar in both groups, except that those receiving the ACCURATE neo had a smaller annulus (358 mm² vs. 366 mm² p=0.004).

To get a homogeneous sample population, propensity score was applied, resulting in 92 pairs.

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Use of temporary pacemaker for valve implantation was similar (12% for the ACCURATE neo and 15.2% for the SAPIENS 3).

At 30 days, mortality was similar (ACCURATE neo 0% vs. SAPIENS 3 1%). There were no differences in stroke (3.3% vs. 3.2%), life threatening bleeding (1.1% vs. 1.1%), vascular complications (2.2% vs. 6.5%), or need for definite pacemaker (12% vs. 15.2%).

At 30 days, Echo-Doppler outcomes showed the ACCURATE neo was superior in terms of lower transvalvular gradient (9.0 mmHg vs. 14.5 mmHg p<0.001), higher effective orifice area (0.96 vs. 0.80 cm²/m²) and lower PPM (3% vs. 22% p=0.004). These data were maintained at one year. The presence of ≥moderate paravalvular regurgitation was low (4.5% vs. 3.6%).

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One-year mortality was numerically lower (though with no statistical importance) in the ACCURATE group (8.3% vs. 13.3%).

Conclusion

While both valves presented the same safety profile, the ACCURATE neo offered lower transvalvular gradient and lower PPM compared to the SAPIENS 3, in patients with a small annulus. These results emphasize the need to carefully choose a prosthesis when patients present a small annulus.

Comment

Even though both prosthesis resulted safe, the need for pacemaker was similar and the need for predilation was higher with the ACCURATE (with no negative impact). This valve showed a better hemodynamic profile and lower PPM at one year.

Therefore, this study shows that we should be extremely careful when choosing a valve for this group, and we should prefer the ACCURATE in this particular situation.

We need further research, as well as further development of new valves for this group of patients.

Gentileza del Dr. Carlos Fava.

Original Title: Short-term Outcome and Hemodynamic Performance of Next-Generation Self-Expanding Versus Balloon-Expandable Transcatheter Aortic Valves in Patients with Small Aortic Annulus. A Multicenter Propensity-Matched Comparison.

Reference: Victor Mauri, Circ Cardiovasc Interv 2017;10e005013.

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