Reclassification of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted versus measured indexed effective orifice area

Abstract

The incidence and impact on outcomes of prosthesis-patient mismatch (PPM) have yielded to discrepant results between transcatheter aortic valve replacement (TAVR). The objective of this study was to compare the incidence and impact on outcomes of measured (PPM M ) versus predicted (PPM P ) PPM following TAVR. All consecutives patients who underwent TAVR between 2007 and 2018 were included. Effective orifice area (EOA) was measured by Doppler-echocardiography using the continuity equation and predicted according to the normal reference for each model and size of valve. PPM was defined using EOA indexed to body surface area (EOAi) as moderate if ≤ 0.85 cm 2 /m 2 and severe if ≤0.65 cm 2 /m 2 (respectively ≤ 0.70 cm 2 /m 2 and ≤ 0.55 cm 2 /m 2 if body mass index ≥ 30 kg/m 2 ). The outcome endpoints were high residual gradient (≥ 20 mmHg) and the composite of cardiovascular mortality and hospital readmission for heart failure at 1 year. Overall, 1088 patients underwent a TAVR (55% male, age 79.1 ± 8.4 years and STS score 6.6 ± 4.7%); balloon-expandable device was used in 83%. Incidence of moderate (10% vs. 27%) and severe (1% vs. 17%) PPM was markedly lower when defined by predicted versus measured EOAi ( P < 0.001). Balloon-expandable device implantation (OR: 1.90, P = 0.029) and valve-in-valve procedure ( n = 118; OR: 3.21, P < 0.001) were the main factors associated with PPM occurrence. Compared to measured PPM, predicted PPM showed stronger association with high residual gradient. Severe measured or predicted PPM was not associated with clinical outcomes ( Fig. 1 ). The utilization of the predicted EOAi reclassifies the majority of patients with PPM to no PPM following TAVR. Compared to measured PPM, predicted PPM had stronger association with hemodynamic outcomes, while both methods were not associated with clinical outcomes.