Clinical Impact of Prosthesis–Patient Mismatch after Surgical Aortic Valve Replacement: A Multicenter Prospective Analysis

Background: Prosthesis–patient mismatch (PPM) is frequent and thought to have a negative impact on short- and long-term mortality and morbidity after surgical aortic valve replacement (SAVR). The aim of the present analysis was to investigate the impact of PPM on 3-year clinical outcomes and left ventricular (LV) mass regression post SAVR.

Methods: Merged data of INDURE and IMPACT real-world observational prospective registries enrolling a total of 993 patients undergoing SAVR across 41 centers in Europe and Canada were used. Inclusion criteria were being ≥18 years of age, undergoing SAVR with or without concomitant coronary artery bypass graft (CABG), supracoronary tube graft, and/or root replacement. After excluding patients not meeting the inclusion criteria, and those with unknown effective orifice area (EOA) and severe aortic regurgitation, a population of 544 patients was divided into two groups (including correction for obesity): moderate/severe PPM (n = 124) and no PPM (n = 420).

Results: Patients with moderate/severe PPM were older than those with no PPM (62.0 versus 59.2 years, p < 0.001) and had a worse functional status at baseline (NYHA III/IV: 44.4% versus 30.5%, p = 0.004). Bicuspid valves were less often present in patients with moderate/severe PPM compared with those with no PPM (41.4% versus 59.9%, p < 0.001). Smaller valves (19–21 mm) were more frequently implanted in the moderate/severe PPM group (24.2% versus 13.8%, p = 0.001). After correcting for BMI (≥30 kg/m²), 3-year freedom from cardiovascular mortality and reoperation were lower in patients with moderate/severe PPM (95.7% versus 98.6%, p = 0.035 and 97.1% versus 99.8%, p = 0.011, respectively), but not clearly linked to the presence of PPM (paravalvular leak, stroke, arrhythmia, endocarditis). Although improved from baseline, mean pressure gradient at 3 years was higher in patients with moderate/severe PPM (14.6 versus 12.7 mm Hg, p = 0.004). NYHA class significantly improved in both groups at 3 years compared with baseline, yet more patients with severe/moderate PPM were still in class III/IV (10.0% versus 3.3%, p = 0.032). LV mass regression was significant at 3 years compared with baseline irrespective of PPM (p < 0.001).

Conclusion: The presence of moderate/severe PPM did not appear to negatively impact clinical outcomes at 3 years, although preoperative correction for BMI should be considered. This would allow for the optimization of valve size choice and decision-making regarding preventive strategies, such as annular enlargement.

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Artikel online veröffentlicht:
11. Februar 2025