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Masiero et al. Mini-invasive Surg 2022;6:4 https://dx.doi.org/10.20517/2574-1225.2021.104 Page 9 of 19

Figure 3. Multidetector computed tomography scan 3D reconstruction showing severe tortuosity of thoracic descending aorta and iliac
arteries.

the screening of TAVI candidates, a lot of anatomical-clinical correlations have become more and more
evident, affording the opportunity to select the most appropriate device for each individual anatomy (and
patient), according to a tailored, patient-centered modern concept of medicine [60-64] . The possible different
choice of THV between a male and a female patient affected by AS is related to different anatomical
characteristics and peculiar pathophysiological features of AS according to sex, as previously detailed.
Women, compared with men, present with particular recurring anatomical characteristics, on which we try
to focus on guiding the choice of the prosthesis in particular circumstances. Recurrent anatomical
characteristics among women affected by AS are the presence of a small body surface area, small anatomic
root (including small annulus, sinus of Valsalva, and sino-tubular junction), low coronary take off, and
small ileo-femoral vessels. Moreover, accumulating evidence suggests that, in patients with degenerative AS,
sex can determine important differences in the pathophysiological processes of development and
progression of AS, leading to a higher prevalence of fibrosis than calcification in stenotic aortic valves of
female patients in comparison to men. Similar differences are also present at the ventricular level, with more
pronounced cardiac hypertrophy and fibrosis in women than men, which translates into concentric
hypertrophic LV remodeling with small and hypertrophic LV cavity, more frequent paradoxical LFLG AS
phenotypes, and final development of heart failure with preserved ejection fraction .
[8]

Considering all these anatomical features, it is possible to speculate which THVs might have potential
advantages in women.

Aortic root anatomy, risk of prosthesis patient mismatch, and coronary occlusion
First, on the basis of the manufacturer’s recommendations, the THVs that cover the smallest annular
dimension (< 21 mm) are CoreValve iterations (Evolut R, Pro and Pro+, Medtronic, Minneapolis,
Minnesota), Edwards Sapien 3/Ultra (Edwards LifeSciences, Irvine, CA, USA), Myval (Meril Life Sciences
Pvt. Ltd., Vapi, Gujarat, India), Portico/Navitor Valve (Abbott Structural Heart, St Paul, MN, USA), and
Allegra valve (New Valve Technology, Hechingen, Germany). Differently, Acurate Neo and Neo 2 valve
(Boston Scientific, Marlborough, MA, USA) are not indicated, according to the sizing chart, for mean
annulus diameter < 21 mm . Moreover, small annuli bear the risk of high residual post-procedural
[63]
gradients and patient-prosthesis mismatch (PPM). Thus, as a general principle, the use of THVs with supra-
annular leaflet attachment, such as CoreValve iterations, may be advantageous in such anatomies, allowing
to achieve the best hemodynamic performances . In the CHOICE-Extend registry which included new
[61]