小径大動脈輪に対する経カテーテル大動脈弁留置術後の人工弁-患者不適合の長期的な影響

Prosthesis-patient mismatch (PPM) remains common following transcatheter aortic valve replacement (TAVR) and is associated with worse clinical outcomes. PPM is of particular concern in small aortic annuli (SAA).

To compare the incidence, predictors, and long-term impact of PPM in SAA TAVR.

Single-center retrospective registry analysis of native, severe aortic stenosis patients with computed tomography-derived annulus area ≤ 430 mm², undergoing TAVR via transfemoral access. Significant PPM was defined as moderate and above and classified by the Valve Academic Research Consortium (VARC)-3. Additional analyses were conducted for predicted PPM and gender-based criteria. Inverse probability treatment weighting (IPTW) was applied to identify predictors of significant PPM and long-term mortality.

The cohort included 631 consecutive patients with SAA undergoing TAVR between 2015 and 2024. Significant PPM occurred in 23.3%. Multivariable analyses identified BEV implantation (OR 2.1, 95% CI 1.3-4.9, p < 0.001) and larger body surface area (OR 4.6, 95% CI 1.7-18.8, p < 0.001) as independent predictors of PPM. Large annulus perimeter had a protective association (OR 0.85, 95% CI 0.79-0.91, p < 0.001). Five-year mortality was significantly higher among patients with significant PPM (32.0% vs. 25.4%; log-rank p = 0.008). Age (HR 1.04, 95% CI 1.004-1.07, p = 0.03), moderate and above paravalvular leak (HR 3.25, 95% CI 1.3-8.0, p = 0.01), and significant PPM (HR 1.97, 95% CI 1.2-3.1, p = 0.004) were independently associated with 5-year mortality.

Significant PPM remains highly prevalent following SAA TAVR. BEV implantation and larger BSA were associated with significant PPM, and a larger implanted valve had a protective association. Significant PPM is independently associated with long-term mortality.