Supra-Annular Versus Intra-Annular Self-Expanding Transcatheter Heart Valves in Patients With Small Aortic Annulus: A Meta-Analysis

Objective Transcatheter aortic valve replacement (TAVR) with self-expanding valves (SEVs) may have different outcomes with supra-annular valves (SAVs) or intra-annular valves (IAVs) in patients with a small aortic annulus (SAA). We aimed to evaluate different SEVs, namely SAVs (CoreValve/Evolut R/PRO/PRO+/FX) versus IAVs (Portico/Navitor). Methods Systematic review and meta-analysis of studies (published until September 2025) comparing SEV-SAV versus SEV-IAV in patients with SAA. Meta-analyses were conducted to assess early outcomes and mortality in the follow-up. Results Five observational studies met our eligibility criteria, including 3303 patients (SAV: 2295; IAV: 1008). We did not find statistically significant differences for 30-day mortality, stroke, acute kidney injury, coronary occlusion, major bleeding, and paravalvular leak; however, we found lower rates of permanent pacemaker implantation in the SAV group (RR 0.75; 95%CI 0.60-0.94; P = .013). Despite slightly larger effective orifice area (mean difference +0.05 cm 2 /m 2 ; 95%CI 0.01-0.10; P = .038), higher indexed effective orifice area (mean difference +0.07 cm 2 /m 2 ; 95%CI 0.01-0.12; P = .012) and slightly lower mean gradients (−0.91 mm Hg; 95%CI −1.77 to −0.05; P = .038) with SAVs, we did not find statistically significant differences in terms of residual mean gradients ≥20 mm Hg (RR 1.65; 95%CI 0.73-3.74; P = .232); however, SAV showed a lower risk of prosthesis-patient mismatch (RR 0.64; 95%CI 0.42-0.98; P = .042). We observed a statistically significant difference in survival at 5 years in favor of the SEV-SAV group (HR 0.770; 95%CI 0.600-0.980; P = .034). Conclusions IAVs and SAVs may have a different performance in terms of hemodynamic structural and nonstructural dysfunction in patients with SAA, which should be confirmed by randomized studies.