Transcatheter or Surgical Aortic Valve Replacement in Women with Small Annuli at Low or Intermediate Surgical Risk

There are limited data from randomized controlled trials assessing the impact of transcatheter aortic valve replacement (TAVR) or surgery in women with aortic stenosis and small aortic annuli. We evaluated 2-year clinical and hemodynamic outcomes following AVR to understand acute valve performance and early and mid-term clinical outcomes. This post hoc analysis pooled women enrolled in the randomized, prospective, multicenter Evolut Low Risk and SURTAVI intermediate risk trials. Women with severe aortic stenosis at low or intermediate surgical risk who had a computed-tomography-measured annular perimeter of ≤ 72.3 mm were included and underwent self-expanding, supra-annular TAVR or surgery. The primary endpoint was 2-year all-cause mortality or disabling stroke rate. The study included 620 women (323 TAVR, 297 surgery) with a mean age of 78 years. At 2 years, all-cause mortality or disabling stroke was 6.5% for TAVR and 8.0% for surgery, p = 0.47. Pacemaker rates were 20.0% for TAVR and 8.3% for surgery, p <0.001. The mean effective orifice area at 2 years was 1.9 ± 0.5 cm2 for TAVR and 1.6 ± 0.5 cm2 for surgery, and the mean gradient was 8.0 ± 4.1 mmHg vs 12.7 ± 6.0 mmHg, respectively (both p <0.001). Moderate or severe patient-prothesis mismatch at discharge occurred in 10.9% of TAVR and 33.2% of surgery patients, p < 0.001. In conclusion, in women with small annuli, clinical outcomes to 2 years were similar between self-expanding, supra-annular TAVR and surgery, with better hemodynamics in the TAVR group, and fewer pacemakers in the surgical group.