Log in to MyACC
Prosthesis-Patient Mismatch After TAVR
Study Questions:
What are the frequency, predictors, and association with outcomes of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR)?
Methods:
The Society of Thoracic Surgeons/American College of Cardiology (STS/ACC) Transcatheter Valve Therapy (TVT) Registry was used to examine PPM after TAVR in 62,125 patients enrolled between 2014 and 2017. Based on the discharge echocardiographic effective valve area indexed to body surface area (EOAI), PPM was classified as severe (<0.65 cm2/m2), moderate (0.65-0.85 cm2/m2), or none (>0.85 cm2/m2). Multivariable regression models were utilized to examine predictors of severe PPM as well as adjusted outcomes, including mortality, heart failure (HF) rehospitalization, stroke, and quality of life (QOL) at 1 year in 37,470 Medicare patients with claims linkage.
Results:
Severe and moderate PPM were present following TAVR in 12% and 25% of patients, respectively. Predictors of severe PPM included small (≤23 mm diameter) valve prosthesis, valve-in-valve procedure, larger body surface area, female sex, younger age, non-White/Hispanic race, lower ejection fraction, atrial fibrillation, and severe mitral or tricuspid regurgitation. At 1 year, mortality was 17.2%, 15.6%, and 15.9% in severe, moderate, and no PPM patients, respectively (p = 0.02). Heart failure (HF) re-hospitalization occurred in 14.7%, 12.8%, and 11.9% of patients with severe, moderate, and no PPM, respectively (p < 0.0001). There was no association between severe PPM and either stroke or QOL score at 1 year.
Conclusions:
Severe PPM after TAVR was present in 12% of patients, and was associated with higher mortality and re-hospitalization for HF at 1 year. The authors concluded that further investigation is warranted to address the prevention of severe PPM in patients undergoing TAVR.
Perspective:
There was debate in years past about whether PPM had clinical impact following surgical AVR. Although the hemodynamics associated with TAVR in general are superior to those following surgical AVR, this study using data from the STS/ACC TVT Registry demonstrates that PPM exists after TAVR, and that it has clear clinical implications. It is not surprising that PPM occurs more frequently after valve-in-valve procedures and among larger patients; however, as the authors suggest, in light of a higher risk for adverse clinical outcomes in the setting of PPM, efforts should be made to identify patients at risk and avoid PPM when feasible.
Keywords: TCT18, Transcatheter Cardiovascular Therapeutics, Atrial Fibrillation, Cardiac Surgical Procedures, Echocardiography, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis, Mitral Valve Insufficiency, Quality of Life, Secondary Prevention, Stroke, Stroke Volume, STS/ACC TVT Registry, Transcatheter Aortic Valve Replacement, Tricuspid Valve Insufficiency
< Back to Listings
