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

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.

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_P) and measured (PPM_M) 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.

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

Despite a higher incidence and severity of both PPM_P and PPM_M, 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.