The Small Aortic Annulus: A Big Challenge in Contemporary TAVI

A small aortic annulus complicates trans catheter aortic valve implantation (TAVI) by limiting prosthetic effective orifice area and increasing the risk of residual gradients and prosthesis–patient mismatch (PPM). This focused narrative review discusses anatomical assessment, valve selection and interpretation of post procedural hemodynamics. Randomized evidence supports better 12-month hemodynamics and fewer bio prosthetic valve dysfunction events with a studied supra-annular self-expanding platform than with an intra-annular balloon-expandable platform. These findings do not establish lower mortality or superior long-term durability. Valve selection should integrate expected hemodynamics with coronary anatomy, conduction risk and future intervention options. Distinguishing measured from predicted PPM and interpreting Doppler findings in relation to flow and the post implantation baseline can help avoid misclassification. Individualized planning should balance valve performance with procedural safety and future treatment options.