Incidence and Sex-Based Comparison of Prosthesis-Patient Mismatch in Patients Undergoing Transcatheter Aortic Valve Replacement.

BACKGROUND

Prosthesis-patient mismatch (PPM) remains a topic of controversy in patients undergoing transcatheter aortic valve replacement (TAVR), particularly among women with smaller annuli. Although self-expanding valves (SEV) appear to provide superior hemodynamic performance than balloon-expandable valves, the impact of PPM severity on long-term survival, particularly regarding sex-specific differences, remains inadequately characterized.

METHODS

This retrospective cohort study analyzed 3016 patients (1338 women) who underwent native valve TAVR from 2012 to 2021. Patients were stratified by sex, valve type (balloon-expandable valve vs SEV), and PPM predicted (PPM) and measured (PPM) severity as defined by the Valve Academic Research Consortium. The primary outcome was all-cause mortality at 5 years, with secondary outcomes including PPM incidence, severity, and residual transvalvular gradients.

RESULTS

Women exhibited higher rates of severe PPM (1.7% vs 0.1%; < .001) and severe PPM (7.3% vs 5.4%; = .033). Notably, neither moderate nor severe PPM or PPM adversely affected 5-year survival in women (severe PPM hazard ratio [HR], 1.24; = .709; severe PPM HR, 1.35; = .168). SEVs were associated with lower overall PPM (12.8% vs 31.8%) and PPM (16.1% vs 31.1%) and superior hemodynamics. Although SEVs demonstrated a nonsignificant lower unadjusted survival (44.4% vs 38.0%; = .286), 5-year survival was similar within PPM strata after risk adjustment (overall PPM HR, 0.51; = .510; overall PPM HR, 0.77; = .412).

CONCLUSIONS

Despite a higher incidence and severity of both PPM and PPM, women did not experience decreased long-term survival after TAVR. Additionally, there was no risk-adjusted survival difference between valve types, emphasizing the need for individualized prosthesis selection and lifetime valve management considerations.