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Borderline annular sizing in transcatheter aortic valve replacement remains challenging because larger and smaller valve strategies involve tradeoffs in procedural risk, valve function, and hemodynamic performance. We evaluated the relationship between balloon-expandable TAVR sizing strategy and follow-up hemodynamics in a retrospective cohort, with focused adjacent valve-size head-to-head comparisons designed to reduce confounding by annular size.

We retrospectively screened balloon-expandable TAVR cases with analyzable procedural sizing data. Sizing strategy was categorized by implanted valve size relative to annular dimensions. A prespecified head-to-head subgroup analysis was performed in overlapping annular ranges where patients could reasonably receive either of 2 adjacent valve sizes, allowing comparison of relative undersizing versus oversizing within the same borderline annular range (e.g., 23-mm oversizing versus 26-mm undersizing). Outcomes included mean aortic valve gradient at 30 days and 1 year, effective orifice area index, and Doppler velocity index. Group-level comparisons were analyzed using unadjusted and adjusted regression models. Longitudinal mean gradient was assessed using a linear mixed-effects model with patient-level random intercepts.

Across overall sizing groups, mean gradient at follow-up did not differ significantly on unadjusted analysis. In pooled head-to-head analysis, gradients were similar between plus- and minus-strategy groups, with no significant difference on unadjusted comparison. In adjusted models, plus-sizing strategy was not independently associated with 1-year mean gradient. In longitudinal mixed-effects analysis, annular area was associated with lower mean gradient and body surface area with higher mean gradient, whereas sizing strategy was not associated with mean gradient.

In a preliminary analysis, plus-sizing strategy was not independently associated with 1-year transvalvular gradient in the adjusted head-to-head model (n=31; difference +1.30 mmHg, p=0.46) or with longitudinal mean gradient in mixed-effects analysis across POD1 through 3 years (152 observations in 44 patients; difference -1.46 mmHg, p=0.13). These findings suggest that patient and annular characteristics may contribute more strongly to follow-up gradients than sizing strategy alone.