Prevalence, predictors, and outcomes of patient prosthesis mismatch in women undergoing TAVI for severe aortic stenosis: Insights from the WIN‐TAVI registry

Abstract

Objective: To evaluate the incidence, predictors and outcomes of female patients with patient-prosthesis mismatch (PPM) following transcatheter aortic valve intervention (TAVI) for severe aortic stenosis (AS). Background: Female AS TAVI recipients have a significantly lower mortality than surgical aortic valve replacement (SAVR) recipients, which could be attributed to the potentially lower PPM rates. TAVI has been associated with lower rates of PPM compared to SAVR. PPM in females post TAVI has not been investigated to date. Methods: The WIN-TAVI (Women's INternational Transcatheter Aortic Valve Implantation) registry is a multicenter registry of women undergoing TAVR for severe symptomatic AS. Two hundred and fifty patients with detailed periprocedural and followup echocardiographic investigations were included in the WIN-TAVI echocardiographic sub-study. PPM was defined as per European guidelines stratified by the presence of obesity. Results: The incidence of PPM in our population was 32.8%. Patients with PPM had significantly higher BMI (27.4 ± 6.1 vs. 25.2 ± 5.0, p = .002), smaller sized valves implanted (percentage of TAVI ≤23 mm 61% vs. 29.2%, PPM vs. no PPM, p < .001) and were more often treated with balloon expandable valves (48.3 vs. 32.5%, p < .001) rather than self expanding ones (26.3 vs. 52.8%, <.001). BMI (OR = 1.08; 95%CI 1.02-1.14, p = .011) and valve size ≤23 mm (OR = 3.00 95%CI 1.14-7.94, p = .027) were the only independent predictors of PPM. There was no significant interaction between valve size and valve type (p = .203). No significant differences were observed in 1-year mortality or major adverse cardiovascular events. Conclusions: PPM in females undergoing TAVI occurs in one third of patients. BMI and valve size ≤23 mm are independent predictors. Larger registries are required to determine the impact of PPM on future clinical outcomes.

Patient Prosthesis Mismatch After SAVR and TAVR

“…The multicenter WIN-TAVI registry ( 45 ), which exclusively enrolled female patients, reported a PPM rate of 32.8%. As described in other studies, in this cohort of female patients higher BMI and smaller TAVI prostheses were the only independent predictors of PPM.…”

Surgical versus transcatheter aortic valve replacement: Impact of patient‐prosthesis mismatch on outcomes

“…The reported PPM rates after SAVR vary more widely than after TAVR, ranging from 8% to almost 80% in SAVR and from 24% to 35% in TAVR. 13,14 We further looked into the incidence of PPM following redo AVR, in which severe PPM after SAVR ranges from 2% to 9% and after valve-in-valve TAVR ranges from 14% to 33%. Short-and midterm survival benefit of the transcatheter approach was not impacted by higher rates of PPM in valve-invalve TAVR.…”

“…There are several baseline clinical characteristics, previously discussed for SAVR, which are also predictive of PPM in TAVR. As seen in SAVR, female sex, younger age, higher BMI, and smaller aortic annulus diameter have all been reported as independent risk factors for the development of PPM in TAVR 14 , 38 EOA indexed to body surface area, however, may lead to an overestimation of PPM in patients with obesity. Thus, recent recommendations suggest applying lower cutoff values of EOA in the patient with BMI ≥ 30: 0.70–0.56 cm 2 /m 2 for moderate PPM, and ≤0.55 m 2 /m 2 for severe PPM 40 .…”

“…14 The incidence of severe PPM has been reported to vary between 4.8%-6%. 14,38 Reports of PPM and its negative impact on survival in TAVR also vary. In contrast to SAVR literature, in TAVR, a meta-analysis examining the effect of PPM on survival showed no effect.…”

Women and transcatheter aortic valve implantation: Also a mismatch could be tomorrow's best match

“…In this issue of the journal, Panoulas et al 4 reported the results of a subanalysis of the WIN‐TAVI registry focused on the occurrence of PPM in women after TAVR. The paper has the commendable merit of combining the need for more data on PPM post TAVR with the cogent need to have gender‐specific data for TAVR.…”