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

Karim Al-Azizi; Taylor Pickering; Mohamad Bader AboHajar; Ghadi Moubarak; Asim Mohiuddin; Srinivasa P Potluri; Sibi Thomas; Imran Baig; Obadah Aqtash; Sanjeev Trehan; Katherine B Harrington; Justin M Schaffer; William T Brinkman; Amro Alsaid; Zuyue Wang; Jonathan Ladner; Rahul Gunukula; Colleen Parro; Tanushree Prasad; Robert Stoler; Yashasvi Chugh; Subhash Banerjee; Timothy Mixon; Robert J Widmer; Angel Caldera; Jose Condado Contreras; Anita Krueger; Janaki Rami Reddy Manne; Prajakta Phatak; Ralph M Matar; William Gray; J Michael DiMaio; Michael J Mack; Molly Szerlip

doi:10.1016/j.jscai.2025.103621

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

J Soc Cardiovasc Angiogr Interv. 2025 May 1;4(7):103621. doi: 10.1016/j.jscai.2025.103621. eCollection 2025 Jul.

Authors

Karim Al-Azizi¹, Taylor Pickering², Mohamad Bader AboHajar², Ghadi Moubarak², Asim Mohiuddin², Srinivasa P Potluri¹, Sibi Thomas¹, Imran Baig¹, Obadah Aqtash¹, Sanjeev Trehan¹, Katherine B Harrington³, Justin M Schaffer³, William T Brinkman³, Amro Alsaid¹, Zuyue Wang¹, Jonathan Ladner², Rahul Gunukula², Colleen Parro², Tanushree Prasad², Robert Stoler⁴, Yashasvi Chugh⁴, Subhash Banerjee⁴, Timothy Mixon⁵, Robert J Widmer⁵, Angel Caldera⁶, Jose Condado Contreras⁶, Anita Krueger⁷, Janaki Rami Reddy Manne¹, Prajakta Phatak¹, Ralph M Matar¹, William Gray^{1

8}, J Michael DiMaio^{2

3}, Michael J Mack^{2

3}, Molly Szerlip¹

Affiliations

¹ Department of Cardiology, Baylor Scott & White The Heart Hospital, Plano, Texas.
² Baylor Scott & White Research Institute, Plano, Texas.
³ Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital, Plano, Texas.
⁴ Department of Cardiology, Baylor University Medical Center, Dallas, Texas.
⁵ Department of Cardiology, Baylor Scott & White Medical Center, Temple, Texas.
⁶ Department of Cardiology, Baylor Scott & White Medical Center, Round Rock, Texas.
⁷ Department of Cardiothoracic Surgery, Baylor Scott & White All Saints Medical Center, Fort Worth, Texas.
⁸ Department of Cardiology, Baylor Scott & White Medical Center, College Station, Texas.

Abstract

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_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.

Results: 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).

Conclusions: 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.

Keywords: balloon-expandable valves; prosthesis-patient mismatch; self-expanding valves; sex differences; transcatheter aortic valve replacement.