Background Excessive aortic cusp calcification increases the risk of periprocedural complications after transcatheter aortic valve replacement (TAVR). Differences in device performance in patients with excessive calcification may affect long-term clinical outcomes.Objectives To compare periprocedural and long-term outcomes between self-expanding (SEV) and balloon-expandable (BEV) prostheses in patients with excess cusp calcification undergoing TAVR.Methods Consecutive patients with severe aortic stenosis and aortic valve complex calcium volume ≥235 mm³ (on contrast images with Hounsfield unit threshold of 850) who underwent TAVR with either CoreValve/Evolut SEV or SAPIEN BEV from August 2007 to June 2023 were included from a prospective-single center registry. A 1:1 propensity-matched analysis was performed to account for baseline differences between groups.Results Among 1,345 patients, 271 matched pairs were identified. Procedural success was achieved in >85% of patients with no difference between groups. Annular rupture occurred more frequently with BEV compared to SEV (2.2% vs 0%, p=0.030). SEV had a lower transprosthetic gradient (8.0 mmHg vs. 11.2 mmHg, p <0.001) but higher rates of mild or greater paravalvular regurgitation (69.7% vs. 58.1%, p=0.008) and new permanent pacemaker implantation (22.6% vs. 15.5%, p=0.001). At 5 years, there was no statistically significant difference in mortality between groups (45.1% vs. 50.2%, p=0.173).Conclusions In patients with excessive leaflet calcification undergoing TAVR, BEV had a higher risk of annular rupture, but a lower risk of paravalvular regurgitation, and a lower risk of permanent pacemaker implantation compared to SEV. Mortality was comparable between SEV and BEV throughout 5 years of follow-up.Clinical Trial Registration https://www.Clinicaltrials gov. NCT01368250.
