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Impact of Prosthesis-Patient Mismatch After TAVR
Quick Takes
- In a study-level meta-analysis of all-cause mortality after TAVR, patients with moderate or severe prosthesis-patient mismatch (PPM) had a significantly higher risk of mortality compared with those without PPM.
- The risk of excess mortality associated with moderate or severe PPM was present for the first 30 months after TAVR but not thereafter.
- In separating the degrees of PPM, excess all-cause mortality was associated with severe PPM compared to no PPM but was not demonstrable for moderate PPM compared to no PPM.
Study Questions:
Does prosthesis-patient mismatch (PPM) affect all-cause mortality following transcatheter aortic valve replacement (TAVR)?
Methods:
A study-level meta-analysis was performed using time-to-event outcomes from prospective or retrospective, randomized or nonrandomized, single-center or multicenter, matched or unmatched population studies published by December 31, 2021, in which patients underwent TAVR, had an echocardiogram after the procedure to measure indexed effective orifice area, included both groups without and with PPM, and included survival and/or mortality with Kaplan-Meier curves.
Results:
In total, 23 studies met eligibility criteria and included a total of 81,969 patients in the Kaplan-Meier curves (19,612 with PPM and 62,357 without PPM). Patients with moderate/severe PPM had a significantly higher risk of mortality compared with those without PPM (hazard ratio [HR], 1.09; 95% confidence interval [CI], 1.04-1.14; p < 0.001). In the first 30 months after the procedure, mortality rates were significantly higher in the moderate/severe PPM group (HR, 1.1; 95% CI, 1.05-1.16; p < 0.001). In contrast, the landmark analysis beyond 30 months yielded a trend toward reversal of the HR (0.83; 95% CI, 0.68-1.01; p = 0.064), but without statistical significance. In the sensitivity analysis, although severe PPM showed higher risk of mortality in comparison with no PPM (HR, 1.25; 95% CI, 1.16-1.36; p < 0.001), there was not a statistically significant difference for mortality between moderate PPM and no PPM (HR, 1.03; 95% CI, 0.96-1.10; p = 0.398).
Conclusions:
Severe PPM, but not moderate PPM, was associated with higher risk of mortality following TAVR. The authors concluded that these results provide support for preventive strategies to avoid severe PPM following TAVR.
Perspective:
Severe PPM is associated with adverse outcomes after surgical aortic valve replacement (SAVR). Although the incidence of severe PPM after TAVR is less than that after SAVR, PPM also has been associated with adverse outcomes after TAVR. This meta-analysis found that the presence of moderate or severe PPM after TAVR is associated with a higher risk of all-cause mortality; that the risk of excess mortality was present for the first 30 months after TAVR but not thereafter; and that, in separating the degrees of PPM, excess all-cause mortality was associated with severe PPM compared to no PPM but was not demonstrable for moderate PPM compared to no PPM. As a meta-analysis, the study is limited, including by nonstandard definitions of PPM in the contributing studies and by the inability to assess the impact of PPM on clinical outcome measures other than all-cause mortality. However, it serves to reinforce the adverse role that PPM has on clinical outcomes, and the importance of measures to try to minimize the risk of leaving patients with PPM following either SAVR or TAVR.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound
Keywords: Cardiac Surgical Procedures, Diagnostic Imaging, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis, Outcome Assessment, Health Care, TCT22, Risk, Secondary Prevention, Transcatheter Aortic Valve Replacement, Transcatheter Cardiovascular Therapeutics
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