Annular Aortic Valve Enlargement Versus Transcatheter Aortic Valve Replacement in Women With Small Aortic Annulus: Contemporary Evidence, Challenges, and Future Directions

Women with severe aortic stenosis frequently have small aortic annuli, predisposing them to prosthesis-patient mismatch after valve replacement. Surgical annular aortic valve enlargement (AAVE) during aortic valve replacement and transcatheter aortic valve replacement (TAVR) are the principal strategies to optimize hemodynamics in this setting. This review compared contemporary evidence on AAVE and TAVR in women with small aortic annuli, focusing on hemodynamic performance, clinical outcomes, procedural risks, and durability. In women with small annuli, supra-annular self-expanding TAVR valves achieve larger indexed effective orifice areas, lower gradients, and reduced moderate prosthesis-patient mismatch compared with balloon-expandable valves and surgical aortic valve replacement, but at the cost of higher vascular complication and pacemaker implantation rates. AAVE permits implantation of larger surgical prostheses, reducing prosthesis-patient mismatch and improving long-term hemodynamics, but increases operative complexity, cardiopulmonary bypass time, and perioperative morbidity. Short-term mortality and stroke are comparable across approaches. Midterm outcomes show similar survival, functional status, and structural valve degeneration between contemporary TAVR and surgical aortic valve replacement; however, surgical prostheses have established 10-year durability, while long-term TAVR durability remains uncertain. Both AAVE and TAVR are viable strategies for women with small annuli. Optimal selection should be individualized based on anatomy, surgical risk, and life expectancy. Randomized trials with sex-specific endpoints and long-term follow-up are needed to refine treatment algorithms and improve outcomes in this high-risk population.