ABSTRACT
Introduction
Small aortic annulus (SAA) poses a challenge in the management of patients with severe aortic stenosis requiring aortic valve replacement – both surgical and transcatheter – since it has been associated with worse clinical outcomes.
Areas covered
This review aims to comprehensively summarize the available evidence regarding the management of aortic stenosis in patients with SAA and discuss the current controversies as well as future perspectives in this field.
Expert opinion
It is paramount to agree in a common definition for diagnosing and properly treating SAA patients, and for that purpose, multidetector computer tomography is essential. The results of recent trials led to the expansion of transcatheter aortic valve replacement among patients of all the surgical-risk spectrum, and the choice of treatment (transcatheter, surgical) should be based on patient comorbidities, anatomical characteristics, and patient preferences.
Article highlights
SAA patients pose a challenge when treating AS since this anatomical feature has been associated with poorer clinical outcomes.
Since 2D techniques may underestimate the annulus diameter, multidetector computer tomography is highly recommended when assessing patients with severe AS prior to intervention.
Avoiding PPM is of outmost importance and, consequently, predicted indexed EOA should be calculated prior to intervention.
Both, SAVR and TAVR have proven to be effective in this clinical scenario. Consequently, the choice of treatment should be based on patient comorbidities, anatomical characteristics and patient preferences.
In SAA patients who are candidates to TAVR, a self-expanding supra-annular valve design may result in a better hemodynamic profile with a lower risk of severe PPM.
Ongoing clinical trials such as SMART, VIVA, and RHEA will provide further information on this controversial topic.
Declaration of interest
J Rodes-Cabau has received institutional research grants and consultant/speaker fees from Edwards Lifesciences, Medtronic, and holds the Research Chair ”Fondation Famille Jacques Larivière” for the Development of Structural Heart Interventions (Laval University, Quebec City, Canada). J Nuche has received a grant from the Fundación Alfonso Martín Escudero (Madrid, Spain) for the development of a research project in a foreign institution.
The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.
Reviewer disclosures
Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.
List of abbreviations
AA | = | aortic annulus |
ARE | = | aortic root enlargement |
AS | = | aortic stenosis |
AVR | = | aortic valve replacement |
BEV | = | balloon-expandable valve |
BMI | = | body mass index |
BSA | = | body surface area |
CABG | = | coronary artery bypass graft |
CT | = | computed tomography |
EOA | = | effective orifice area |
iEOA | = | indexed effective orifice area |
MDCT | = | multi detector computed tomography |
LV | = | left ventricle |
LEVF | = | left ventricular ejection fraction |
LVOT | = | left ventricular outflow tract |
PPM | = | prosthesis-patient mismatch |
PVL | = | paravalvular leak |
SAA | = | small aortic annulus |
SAVR | = | surgical aortic valve replacement |
SEV | = | self-expandable valve |
SRDV | = | sutureless and rapid deployment valve |
SVD | = | structural valve deterioration |
TAVR | = | transcatheter aortic valve replacement |
THV | = | transcatheter heart valve |
TTE | = | transthoracic echocardiography |