Impact of Balloon Post-Dilation on the Long-Term Durability of Bioprostheses after TAVR

Balloon post-dilation (BPD) during transcatheter aortic valve replacement (TAVR) allows for the optimization of prosthesis expansion and the reduction of residual paravalvular aortic regurgitation. However, its use has been controversial due to the potential generation of increased mechanical stress on the leaflets, with the consequent risk of compromising the long-term durability of the bioprosthesis. The aim of this study was to evaluate the impact of BPD on long-term valve durability as assessed through hemodynamic valve deterioration and bioprosthetic valve failure.

Researchers conducted a prospective observational analysis based on a single-center registry from the Québec Heart & Lung Institute (Laval University, Canada), which included 1911 consecutive patients with severe aortic stenosis who underwent TAVR between May 2007 and March 2024. The mean age was 79±8 years, and 43% of patients were women. Balloon post-dilation was performed in 294 patients (15%), primarily to reduce paravalvular regurgitation (88%) and, to a lesser extent, for hemodynamic optimization (12%). Balloon-expandable and self-expanding valves were implanted in 69% and 31% of cases, respectively, with a similar frequency of post-dilation for both types (15% vs. 16%). The median follow-up was 4 years (interquartile range: 2–5).

The primary endpoint was the occurrence of stage 2 or 3 hemodynamic valve deterioration, according to VARC-3 criteria. Secondary endpoints included major clinical events and the incidence of bioprosthetic valve failure, defined as the presence of stage 3 hemodynamic valve deterioration, need for reintervention, or mortality attributable to prosthetic dysfunction.

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The incidence of stage 2 or 3 hemodynamic valve deterioration was significantly lower in the BPD group compared with the group without post-dilation (2.8% vs. 5.8%; p=0.039). Consistently, bioprosthetic valve failure occurred less frequently in patients who underwent BPD (2.8% vs. 5.1%; p=0.046). There were no significant differences in the isolated incidence of stage 3 hemodynamic deterioration (1.0% vs. 2.0%; p=0.233). Echocardiographic follow-up showed lower mean transaortic gradients and larger effective orifice areas in the BPD group (p=0.001 and p <0.001, respectively), whereas patients without post-dilation exhibited a progressive increase in gradients.

Regarding clinical events, there were no differences in all-cause mortality, cardiovascular mortality, stroke, valve reintervention, or major bleeding. There was a trend toward a higher rate of hospitalizations for heart failure in the BPD group (26% vs. 18%; hazard ratio [HR] 1.37; 95% confidence interval [CI]: 0.98–1.89; p = 0.059), but it did not reach statistical significance.

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In subgroup analyses, the reduction in stage 2–3 hemodynamic valve deterioration associated with post-dilatation was more pronounced with balloon-expandable valves (sHR 0.32; 95% CI: 0.11–0.92; p=0.035), with no significant effect observed in self-expanding valves.

Conclusion

In this single-center registry, balloon post-dilatation during TAVR was associated with a lower incidence of stage 2 or 3 hemodynamic valve deterioration and bioprosthetic valve failure, along with better long-term hemodynamic parameters, without an adverse impact on the mortality or stroke risk. These findings support the safety of BPD and suggest a potential benefit in valve durability.

Original Title: Impact of Balloon Postdilation on Long-Term Bioprosthesis Durability After TAVR.

Reference: Antonin Trimaille, MD, et al. Circulation: Cardiovascular Interventions, Volumen 18, e015577, diciembre de 2025. DOI: 10.1161/CIRCINTERVENTIONS.125.015577.