Wednesday, November 27, 2024

Advanced Insights on Balloon-Expandable TAVI in Small Aortic Annuli: A Five-Year Perspective

 Key Findings:

  • Balloon-expandable TAVI demonstrates comparable outcomes to surgery in low-risk patients with symptomatic severe aortic stenosis across both small and large annuli at five years.
  • The SMART trial earlier indicated that self-expanding valves might outperform balloon-expandable valves at one year, particularly in hemodynamic performance.
  • The latest PARTNER 3 analysis suggests similar rates of aortic valve reintervention and bioprosthetic valve failure between the two treatment options.

Clinical Insights and Outcomes:

  • For patients with small annuli, the primary endpoint of death, stroke, or rehospitalization was slightly lower for TAVI (21.2%) than surgery (31.6%) at five years, though not statistically significant.
  • Quality-of-life outcomes were comparable between TAVI and surgery, regardless of annular size.
  • The RHEIA trial, focusing on women (who typically have smaller annuli), revealed fewer rehospitalizations with TAVI compared to surgery.

Device Evolution and Comparisons:

  • The Resilia valve, an updated balloon-expandable model, shows improved hemodynamics over older versions, narrowing the performance gap with self-expanding valves like Evolut FX.
  • Despite Evolut FX maintaining superior hemodynamics, Resilia's advancements include reduced rates of paravalvular leak and better technical device success.

Take-Home Points:

  1. Annular size does not significantly impact clinical outcomes between TAVI and surgery at five years for low-risk patients.
  2. Advancements in balloon-expandable valves have improved performance metrics, reducing concerns about prosthesis-patient mismatch (PPM) and hemodynamic dysfunction.
  3. TAVI is a reliable option for low-risk patients, including those with small annuli, and its outcomes are comparable to surgery.
  4. Long-term durability data is crucial for understanding valve performance beyond five years.

This analysis underscores the progress in TAVI technology and clarifies clinicians when deciding between surgical and transcatheter interventions, particularly for patients with small aortic annuli.

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