Managing the challenge of a small aortic annulus in patients with severe aortic stenosis

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.

KEYWORDS:

• Aortic stenosis
• heart valve prosthesis
• surgical aortic valve replacement
• small aortic annulus
• transcatheter aortic valve replacement

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

Additional information

Funding

This paper was not funded.