University of Cologne, Faculty of Medicine and University Hospital Cologne, Clinic III for Internal Medicine, Cologne, Germany.
Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
JACC Cardiovasc Interv. 2024 Nov 25;17(22):2626-2635. doi: 10.1016/j.jcin.2024.08.041.
Prosthesis-patient mismatch after transcatheter aortic valve replacement (TAVR) can be measured echocardiographically (measured prosthesis-patient mismatch [PPMm]) or predicted (predicted prosthesis-patient mismatch [PPMp]) using published effective orifice area (EOA) reference values. However, the clinical implications of PPM post-TAVR remain unclear.
This study aimed to elucidate the prevalence of PPMm and PPMp post-TAVR and their impact on mortality in a large international cohort.
The IMPPACT TAVR (Impact of Measured or Predicted Prosthesis-pAtient mismatCh after TAVR) registry included 38,808 TAVR patients from 26 international centers. Valve Academic Research Consortium 3 criteria were used to define prosthesis-patient mismatch severity. EOA was determined echocardiographically (PPMm) or predicted (PPMp) based on core lab-derived EOA reference values. The primary endpoint was 2-year all-cause mortality.
The prevalence of PPMp (moderate: 6.8%, severe: 0.6%) was significantly lower than that of PPMm (moderate: 20.7%, severe: 4.3%; P < 0.001) with negligible correlation between the 2 methods (Kendall's tau c correlation coefficient: 0.063; P < 0.001). In unadjusted analyses, severe PPMm adversely influenced 2-year survival (HR: 1.22; 95% CI: 1.02-1.45; P = 0.027), whereas severe PPMp was not associated with outcomes (HR: 0.81; 95% CI: 0.55-1.19; P = 0.291). After adjusting for confounders, neither PPMm nor PPMp had a significant effect on 2-year all-cause mortality.
PPMm and PPMp were associated with different patient characteristics, with PPMm tending toward worse (especially low flow) and PPMp toward better (especially women) survival. After adjusting for confounders, neither PPMm nor PPMp significantly affected 2-year all-cause mortality. Hence, valve selection should not solely be based on hemodynamics but rather on a holistic approach, including patient and procedural specifics.
经导管主动脉瓣置换术（TAVR）后人工瓣膜-患者不匹配可通过超声心动图测量（测量的人工瓣膜-患者不匹配[PPMm]）或预测（预测的人工瓣膜-患者不匹配[PPMp]），使用已发表的有效瓣口面积（EOA）参考值。然而，TAVR 后 PPM 的临床意义仍不清楚。
本研究旨在阐明大国际队列中 TAVR 后 PPMm 和 PPMp 的发生率及其对死亡率的影响。
IMPACT TAVR（经导管主动脉瓣置换术后测量或预测的人工瓣膜-患者不匹配的影响）登记研究纳入了来自 26 个国际中心的 38808 例 TAVR 患者。采用瓣膜学术研究联合会 3 项标准定义人工瓣膜-患者不匹配的严重程度。EOA 通过核心实验室衍生的 EOA 参考值进行超声心动图测量（PPMm）或预测（PPMp）。主要终点为 2 年全因死亡率。
PPMp（中度：6.8%，重度：0.6%）的发生率明显低于 PPMm（中度：20.7%，重度：4.3%；P<0.001），两种方法之间相关性较低（Kendall tau c 相关系数：0.063；P<0.001）。在未调整分析中，严重 PPMm 对 2 年生存率有不利影响（HR：1.22；95%CI：1.02-1.45；P=0.027），而严重 PPMp 与结局无关（HR：0.81；95%CI：0.55-1.19；P=0.291）。调整混杂因素后，PPMm 和 PPMp 均与 2 年全因死亡率无显著相关性。
PPMm 和 PPMp 与不同的患者特征相关，PPMm 倾向于较差（尤其是低流量），PPMp 倾向于较好（尤其是女性）生存。调整混杂因素后，PPMm 和 PPMp 均未显著影响 2 年全因死亡率。因此，瓣膜选择不应仅基于血流动力学，而应采用包括患者和手术特点在内的整体方法。
