Impact of Balloon‐Expandable Valve Asymmetry on Heart Failure Post Transcatheter Aortic Valve Replacement

Background Fluoroscopic assessment enables immediate evaluation of transcatheter heart valve expansion during transcatheter aortic valve replacement (TAVR). Whether fluoroscopic asymmetric expansion of balloon‐expandable valves is associated with post‐TAVR heart failure (HF) remains uncertain. Methods Among 607 consecutive patients undergoing balloon‐expandable valve‐TAVR in a prospective registry, 589 were analyzed. Valve asymmetry was quantified using a fluoroscopic asymmetry index (%), defined as [(longest/shortest balloon‐expandable valve height)−1]×100. The primary end point was 2‐year HF hospitalization. Results During follow‐up, 99 patients (17%) experienced HF hospitalization. As a continuous variable, asymmetry index (%) was not independently associated with 2‐year HF (adjusted hazard ratio [HR] per 1% increase, 1.02 [95% CI, 0.98–1.06]). Restricted cubic spline analysis demonstrated no significant linear or nonlinear association (overall P =0.71; P for nonlinearity=0.89), although the risk curve suggested increased HF risk beyond moderate valve asymmetry. Exploratory threshold analysis identified an asymmetry index cutoff of 7.48%. Patients above this threshold had a higher incidence of HF hospitalization than those below it (23.6% versus 15.8%; log‐rank P =0.043), despite comparable rates of impaired valve performance at discharge. Valve asymmetry >7.48% remained independently associated with late HF occurring beyond 30 days after TAVR (adjusted HR, 1.69 [95% CI, 1.10–2.60]). Conclusions Fluoroscopic assessment of balloon‐expandable valve expansion identified patients with marked valve asymmetry at increased risk of late HF after TAVR, despite preserved early valve performance. These findings support the potential value of intraprocedural valve geometry assessment for long‐term risk stratification and warrant further investigation.