The Impact of THV Platforms on Transfemoral TAVR in Complex Vascular Access: Insights From the Hostile Registry

Background: The choice of transcatheter heart valve (THV) platform, including self-expanding valves (SEVs) and balloon-expandable valves (BEVs), may influence outcomes in patients with peripheral artery disease (PAD) undergoing transfemoral transcatheter aortic valve replacement (TAVR). This relationship remains underexplored in high-risk populations with challenging vascular access. Aims: This study assessed the impact of SEVs and BEVs on clinical outcomes in PAD patients, considering hostile score severity. Methods: This sub-analysis of the Hostile Registry included 419 TAVR patients (47% SEVs, 53% BEVs). Outcomes, including all-cause mortality, stroke, vascular complications, and major bleeding were evaluated at 30 days and 1 year. Logistic regression and Cox proportional hazard models assessed associations, with interaction terms exploring the modifying effect of valve type by hostile score severity. Results: No significant differences emerged between SEVs and BEVs for 30-day and 1-year outcomes. However, in SEVs recipients, a high hostile score was associated with worse outcomes, including 1-year all-cause mortality (HR 2.81, p = 0.033), stroke (HR 18.26, p = 0.008), major bleeding (HR 2.49, p = 0.033), and MACCE (HR 4.34, p < 0.001). Interaction terms were not statistically significant, although a trend for MACCE (p = 0.0598) was noted. Conclusions: SEVs and BEVs demonstrated comparable outcomes overall, high hostile score were associated with worse outcomes in the SEV group. Nonetheless, there was a trend suggesting a difference between the two valves in this setting, and further studies are needed to confirm potential valve-specific differences in high-risk populations and to refine personalized valve selection.