Routine postdilation with a balloon-expandable transcatheter heart valve (THV) optimized THV geometry and improved hemodynamic performance, without increasing procedure-related adverse events in patients with severe aortic stenosis (AS), according to results from the DUOTAP trial presented at TCT 2026 and simultaneously published in JAMA Cardiology.

Researchers randomized 148 patients with severe AS suitable for transfemoral TAVI with a balloon-expandable THV and without high-risk features on preprocedural computed tomography (CT) or coronary angiography to either routine postdilation or no postdilation. The average age of participants was 81 years and nearly half were female. The fluoroscopic THV asymmetry index served as the primary endpoint.

Results showed that postdilation yielded a 70% lower THV asymmetry index compared with no postdilation (median: 1.2% vs 2.8%), with consistent effects observed across prespecified groups. Postdilation also yielded larger THV diameters on fluoroscopy and significantly larger THV areas at the inflow, midframe and outflow level on CT. Researchers also noted that hypoattenuated leaflet thickening (HALT) and mild or worse paravalvular leak (PVL) were significantly less frequent in those assigned to routine postdilation. There were no differences in procedure-related adverse events between the two groups.

“By providing randomized evidence that THV asymmetry is modifiable intraprocedurally, the DUOTAP trial challenges the concept of THV geometry as a passive consequence of valve deployment and supports geometry optimization as an actionable therapeutic target during contemporary TAVI procedures,” said Maximilian Autherith, MD, et al. “Whether these mechanistic and hemodynamic benefits translate into improved valve durability and long-term clinical outcomes remains to be assessed.”

In a related editorial comment, John G. Webb, MD, FACC, and Lucca Loretz, MD, say the DUOTAP findings confirm and extend findings from previous studies assessing routine postdilation – demonstrating “favorable structural, functional and clinical outcomes.” As a result, they suggest that “double tap postdilation seems a reasonable strategy which should be adopted more widely – if not routinely, then at least more often.”

Clinical Topics: Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Computed Tomography, Nuclear Imaging

Keywords: Transcatheter Cardiovascular Therapeutics, TCT26, Coronary Angiography, Aortic Valve Stenosis, Heart Valves, Hemodynamics, Fluoroscopy, Tomography, Tomography, X-Ray Computed