Transcatheter Aortic Valve Replacement in Patients With Small Aortic Annuli: A Propensity-Matched Analysis of Gender-Based Outcomes

Abstract

Background: Patients with small aortic annuli (SAA) are predominantly women. We sought to compare sex-based and propensity-matched outcomes of index transcatheter aortic valve replacement (TAVR) in patients with SAA. Methods: In this retrospective institutional analysis (2012 – 2023), primary stratification was by gender. SAA was defined as aortic valve annulus diameter <23mm. 30-day and 1-year outcomes were compared between the groups. Results: A total of 3911 patients underwent TAVR. Of those, 661 patients had a small aortic annulus of whom 23.8% were men & 76.2% were women. Propensity matching (1:1) identified 152 pairs. The mean age was 81 years. History of prior surgical or percutaneous coronary intervention was more prevalent in men (72.4% vs 48%, p<0.001). Men had a higher incidence of postoperative pacemaker implantation (8.6% vs 3.3%, p=0.05) while only women had iliofemoral dissections (4.6% vs 0%, p=0.007). The rates of moderate (23.0% vs 25.7%) and severe (2.6% vs 0.7%) prosthesis-patient mismatch was not statistically significantly different between the groups (p=0.364). 30-day mortality was 0% while 1-year mortality was 4.3% with no difference between groups. Increase in preoperative creatinine was associated with higher risk of death (HR 1.206, 95% CI 1.025-1.418, p=0.02), while sex was not. Kaplan-Meier survival estimates (Logrank, p=0.768) and cumulative incidence of stroke readmission (p=0.842) were similar in both groups. Conclusion: Outcomes of TAVR in SAA do not differ by sex with safety and efficacy evident in both men and women.