Intraannular Balloon-Expandable vs. Self-Expanding Transcatheter Heart Valves in Patients with Small Aortic Annuli: A Propensity-Matched Analysis

All articles of this category (opens in new window) Background: Patients with small aortic annuli represent a challenging subset for transcatheter aortic valve implantation (TAVI). While balloon-expandable (BE) valves are consistently deployed in an intraannular position, self-expanding (SE) valves offer both supra- and intraannular designs. However, direct comparisons of intraannular BE and SE platforms in patients with small annuli are limited. This study aimed to evaluate clinical and hemodynamic outcomes of BE vs. SE intraannular transcatheter heart valves (THV) in patients with small annuli. Methods: Between 2021 and 2024, patients with an aortic annulus ≤ 23 mm (perimeter derived) undergoing TAVI at our institution were retrospectively analyzed. A 1:1 propensity score matching (PSM) was performed for BE and intraannular SE THV, matched for age, sex, and major comorbidities. Early procedural, hemodynamic, and clinical outcomes were assessed according to VARC-3 criteria. Results: A total of 84 patients (mean age 80.9 ± 5.9 years, 86.9% female) were included after PSM (42 BE vs. 42 SE). Device success was high in both groups (95.2% BE vs. 97.6% SE, p = 0.562). Thirty-day mortality, myocardial infarction, and acute kidney injury stage ≥ 2 did not occur in either group. Disabling stroke occurred infrequently (0% BE vs. 2.4% SE, p = 0.161). New permanent pacemaker implantation was low and comparable (7.2% BE vs. 4.8% SE, p = 0.651). Postprocedural mean transvalvular gradients were significantly lower with SE valves (6.9 ± 2.8 mmHg vs. 13.3 ± 4.8 mmHg, p < 0.001), while moderate-to-severe paravalvular leak remained rare in both groups (4.8% vs. 2.4%, p = 0.079). Procedure time was numerically shorter with BE valves (50 vs. 57 minutes, p = 0.396). Minor access-site complications occurred in one patient (0% vs. 2.4%, p = 0.312). Conclusion: In this propensity-matched comparison of patients with small aortic annuli, intraannular SE and BE THV achieved excellent and equivalent short-term outcomes. Intraannular SE valves provided remarkably lower postprocedural gradients, whereas BE valves were associated with shorter procedure times. Both platforms represent safe and effective options in this challenging anatomical subset, with device-specific performance characteristics that may guide individualized prosthesis selection. Whether the superior hemodynamics of intraannular SE THV in small aortic annuli translates into improved long-term durability should be the subject of further investigation. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany