Results from the VIVA trial comparing hemodynamic and clinical outcomes between TAVR and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) and small aortic annulus (SAA) provide important insights into how best to treat this patient population. The findings presented Oct. 26 during TCT 2023 and simultaneously published in Circulation show both TAVR and SAVR to be "valid alternatives."

Researchers randomized 151 patients with severe AS and SAA (mean diameter <23 mm) to either TAVR (n=77) or SAVR (n=74). The mean age of participants was 75 year and 93% were women. The primary outcome was impaired valve hemodynamics, including severe prosthesis patient mismatch (PPM) or moderate-severe aortic regurgitation (AR) at 60 days as evaluated by Doppler-echocardiography.

Overall findings showed no significant differences between the TAVR and SAVR groups in the rate of severe PPM (5.6% vs. 10.3%) or moderate-severe AR (none in both groups). In addition, no significant differences were observed between the TAVR and SAVR groups in terms of mortality (1.3% vs. 1.4%) and stroke (0 vs. 2.7%) at 30 days. After a median follow-up of two years, there were also no differences between groups with regards to mortality (9.1% vs. 8.1%), stroke (3.9% vs. 4.1%), and cardiac hospitalization (19.5% vs. 20.3%).

"In this challenging population, there was no evidence of contemporary TAVR superiority vs. SAVR regarding valve hemodynamic outcomes as evaluated by Doppler echocardiography, with relatively low rates of severe PPM in both groups," said Josep Rodés-Cabau, MD, PhD, FACC, and colleagues. "The results of this trial suggest that these two therapies represent a valid alternative for treating patients with AS and SAA."

Looking ahead, Rodés-Cabau, et al., note that the vast majority of low-to-intermediate risk AS patients exhibiting the anatomic feature of SAA were women," underscoring the likely benefits of individualizing treatment selection "according to baseline characteristics, additional anatomical risk factors and patient preference." However, they add that future larger studies are needed to confirm their results, given the small sample size of this current study.