A method that involves a second balloon inflation during transcatheter aortic valve replacement (TAVR) may improve valve expansion without increasing in-hospital or 30-day complications, according to new study findings. In patients who experienced underexpansion of the SAPIEN 3 Ultra Resilia (S3UR) valve (Edwards Lifesciences), and underwent the double-inflation approach, measurements found meaningful increases in frame expansion and foreshortening, with no procedure-related in-hospital adverse events reported. At 30 days, mortality was 1.5%, and stroke occurred in 3% of patients, while no patient exhibited more than mild paravalvular leak. “Fluoroscopy showed that all valves were underexpanded at mid-frame irrespective of valve size and asymmetrical expansion was seen with less foreshortening at the outer curve,” the paper’s authors wrote, led by Parasuram Krishnamoorthy, MD, from the University of Oklahoma Medical Center in Oklahoma City. “Better expansion was seen after post dilatation in all cases with no intraprocedural complications and acceptable hemodynamic performance.” Structural vulnerability The U.S.-based research team noted that consistent mid-frame underexpansion seen across all valve sizes emphasized a structural vulnerability of the newest-generation balloon-expandable platform. While the double-inflation technique significantly improved overall frame geometry, the investigators added that some residual underexpansion may persist, particularly when compared with manufacturer-listed nominal dimensions. They commented that the benefit of the technique was linked to careful patient selection. Operators avoided post-dilatation in individuals with severe annular or left ventricular outflow tract calcification, advanced age or limited tolerance for repeated rapid pacing runs. According to the research team, this conservative approach could explain the low complication rate observed in the study. New reference values The study also provided new reference values for S3UR valves derived from in-vitro fluoroscopy, which closely aligned with previously validated CT-based dimensions. The team commented that they may offer clinicians a more accurate intraoperative benchmark when assessing whether a valve is fully expanded. Concluding the study, the authors also said that optimal frame expansion was increasingly recognized as an important factor in long-term valve durability, leaflet motion and overall hemodynamic performance. They went onto stress that longer-term follow-up was necessary to determine whether improved expansion translates into better durability and reduced structural valve deterioration over time. Source Krishnamoorthy P, Onishi T, Singh S, et al. Double Inflation (“Double Tap”) on Valve Expansion and Short-Term Outcomes after the Latest-Generation Balloon-expandable TAVR, JACC: Cardiovascular Interventions. 2025 November 24 (Article in Press). Image Credit: JM1366 – stock.adobe.com