Balloon-Expandable Versus Self-Expanding Valves in Transcatheter Aortic Valve Replacement for Patients with Left Ventricular Systolic Dysfunction-Uncorrected Proof

Objective: Patients with severe aortic stenosis (AS) and left ventricular systolic dysfunction (LVSD) represent a particularly fragile subgroup undergoing transcatheter aortic valve replacement (TAVR). Comparative outcome data for balloon-expandable valves (BEV) and self-expanding valves (SEV) in this population remain scarce.

Method: This retrospective single-center study evaluated 246 consecutive subjects with left ventricular ejection fraction (LVEF) < 50% who underwent transfemoral TAVR between January 2015 and June 2025. Clinical, echocardiographic, and procedural characteristics were compared between BEV (n = 96) and SEV (n = 150) recipients. Long-term all-cause mortality served as the primary endpoint.

Results: Individuals treated with BEV were older (78.8 ± 7.9 vs. 75.7 ± 9.8 years; P = 0.019) and demonstrated higher EuroSCORE II (European System for Cardiac Operative Risk Evaluation II) values (24.9 ± 6.2% vs. 22.2 ± 15.8%; P = 0.01). Periprocedural and in-hospital clinical outcomes, including mortality, vascular complications, and pacemaker requirement, were comparable between groups. SEV implantation yielded lower post-procedural transvalvular gradients (mean 7.8 ± 4.0 mmHg vs. 9.6 ± 4.1 mmHg; P = 0.001). Although crude mortality was observed more frequently among BEV patients (50.0% vs. 36.0%; P = 0.041), Kaplan–Meier survival curves showed no survival difference (log-rank P = 0.92). In multivariable Cox regression, predictors of long-term mortality included older age (hazard ratio [HR] 1.05; P = 0.007), chronic obstructive pulmonary disease (COPD) (HR: 2.64; P < 0.001), coronary artery disease (HR: 2.08; P = 0.018), lower serum albumin (HR: 0.63; P = 0.011), and lower hemoglobin (HR: 0.84; P = 0.023); valve type was not predictive.

Conclusion: In patients with LVSD undergoing TAVR, BEV and SEV provided comparable procedural and long-term outcomes. Although SEV yielded lower postoperative gradients, valve type did not affect survival. Future studies with larger samples and higher use of new-generation devices are warranted to refine valve selection in this high-risk group.

Keywords: Balloon-expandable valve, low-flow low-gradient aortic stenosis, self-expanding valve, transcatheter aortic valve implantation, transcatheter aortic valve replacement