SAVR or TAVI for Patients with Small Aortic Annuli in Aortic Stenosis?

All articles of this category (opens in new window) Background: A small aortic annulus is associated with increased risk of prosthesis–patient mismatch (PPM) and adverse outcomes following valve replacement. Surgical aortic valve replacement (SAVR) with or without root enlargement (ARE) allows implantation of larger prostheses, while transcatheter aortic valve implantation (TAVI) provides supra-annular positioning and less invasiveness. The study aimed to compare clinical and hemodynamic outcomes of SAVR vs. TAVI in patients with small aortic annuli. Methods: We retrospectively analyzed all patients undergoing aortic valve replacement at our institution between January 2021 and December 2024 ( n = 1,323). Patients with a small annulus (≤430 mm 2 by computer tomography) were identified and assigned to SAVR ( n = 118, including a minority with ARE) or transfemoral TAVI ( n = 183). The primary endpoint was PPM and transvalvular hemodynamics, including mean transvalvular gradient and paravalvular leakage (PVL). Secondary endpoints included effective orifice area (EOA), permanent pacemaker implantation (PPI), and composite endpoint of clinical efficacy at 1 to 4 years according to VARC-3 criteria (composite of all-cause mortality, stroke, valve-related rehospitalization, and deterioration of quality of life). Results: Mean age was 65.3 ± 7.3 years in the SAVR group vs. 80.9 ± 6.6 years in the TAVI group ( p = 0.01). Male sex comprised 32.8% vs. 20.2% ( p = 0.02). EuroSCORE II was 1 ± 0.6% vs. 4.1 ± 3.9% ( p = 0.01). SAVR resulted in a larger EOA (2.4 ± 0.8 cm 2 vs. 1.65 ± 0.5 cm 2 , p = 0.04), but no differences in mean transvalvular gradient (9.1 ± 4.4 mmHg vs. 8.7 ± 4.8 mmHg, p = 0.21) compared with TAVI. The incidence of moderate or severe PPM was markedly lower after SAVR (11.8% vs. 22.1%, p = 0.03). By contrast, moderate/severe PVL occurred more frequently in TAVI (0.8% vs. 4.9%, p = 0.05), as did PPI (5.8% vs. 13.7%, p = 0.01). Mean length of hospital stay was shorter following TAVI (8.8 ± 5.5 vs. 6.5 ± 6.3 days, p = 0.01). One-year survival and the composite clinical efficacy endpoint were significantly better after SAVR ( p = 0.05). Conclusion: In this real-world cohort of patients with small aortic annuli, SAVR achieved more favorable hemodynamic performance and lower PPM rates than TAVI. While TAVI offered procedural advantages, higher PVL and pacemaker rates remain relevant limitations. These findings support the continued role of SAVR as the standard strategy for small annuli, with TAVI considered selectively. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany