Background: Transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis (AS) and large aortic annuli can be challenging because of prothesis size limitations.

Methods: We retrospectively reviewed our TAVI database and identified 42 patients who had received a 29mm balloon expandable valve (BEV) despite having an annular area greater than the manufacturer-recommended upper limit of 683mm² or area-derived diameter greater than 29.5mm, as determined in pre-procedural CT. Procedural and in-hospital outcome data were collected.

Results: All patients were male, mean age was 78.7±6.2 years. EuroScore II was 6.47±8.05. 36 (81%) patients suffered from dyspnea equivalent to NYHA stadium III prior to TAVI. Mean aortic annulus area measured by pre-procedural CT was 944.2±4.38 mm² with an area-derived diameter of 30.9±1.4 mm. Mean aortic gradient before TAVI as measured by echocardiography was 40.12±15.78 mmHg. Intra-procedural valve pre-dilation was performed in 19 cases (44%), while post-dilation was necessary in 4 (9%) patients. Balloon overinflation of 2 to 4 ml was used to adapt valve size to the annulus. All procedures were completed successfully. Mean aortic gradient after TAVR was 10.16±4.85 mmHg, 7 patients (16%) showed a mild residual aortic insufficiency. Post-procedural, 5 patients (11%) required permanent pacemaker implantations. One patient (2%) experienced a stroke. One intra-hospital death occurred.

Conclusions: TAVR using a 29-mm S3 represents an effective treatment option in patients with severe AS and very large annuli.