A strategy of underexpansion and ad hoc post-dilation of balloon-expandable transcatheter aortic valves in patients at risk of annular injury favorable mid-term outcomes

John S. Tan, Jonathon Leipsic, Gidon Perlman, Dion Stub, Danny Dvir, Nicolaj C. Hansson, Bjarne L Norgaard, Philipp Blanke, Anson Cheung, Jian Ye, Christopher R. Thompson, Robert R. Moss, Sandra Lauck, David Wood, John Webb

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25 Citations (Scopus)


Objectives The aim of this study was to evaluate a strategy of intentional underexpansion of excessively oversized balloon-expandable transcatheter heart valves (THVs) in terms of clinical outcomes, valve function, and frame durability at 1 year. Background Transcatheter aortic valve replacement requires the selection of an optimally sized THV to ensure paravalvular sealing and fixation without risking annular injury. However, some patients have "borderline" annular dimensions that require choosing between a THV that may be too small or another that may be too large. Methods We evaluated 47 patients at risk of annular injury who underwent transcatheter aortic valve replacement (TAVR) with an oversized, but deliberately underexpanded, THV followed by post-dilation if required. Clinical evaluation, echocardiography, and cardiac computed tomography were performed pre-TAVR, post-TAVR, and at 1 year. Results Deployment of oversized THVs with modest underfilling of the deployment balloon (<10% by volume) was not associated with significant annular injury. Paravalvular regurgitation was mild or less in 95.7% of patients, with post-dilation required in 10.7%. THV hemodynamic function was excellent and remained stable at 1 year. Computed tomography documented stent frame circularity in 87.5%. Underexpansion was greatest within the intra-annular THV inflow (stent frame area 85.8% of nominal). There was no evidence of stent frame recoil, deformation, or fracture at 1 year. Conclusions In carefully selected patients with borderline annulus dimensions and in whom excessive oversizing of a balloon-expandable SAPIEN XT valve (Edwards Lifesciences, Inc., Irvine, California) is a concern, a strategy of deliberate underexpansion, with ad hoc post-dilation, if necessary, may reduce the risk of annular injury without compromising valve performance.

Original languageEnglish
Pages (from-to)1727-1732
Number of pages6
JournalJACC: Cardiovascular Interventions
Issue number13
Publication statusPublished - Nov 2015
Externally publishedYes


  • aortic valve
  • sizing
  • transcatheter aortic valve replacement

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