Impact of Prosthesis‐Patient Mismatch After Surgical Mitral Valve Replacement: Systematic Review and Meta‐Analysis

The long-term clinical impact of mitral prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) remains incompletely defined.We aimed to systematically assess the prevalence of mitral PPM and its association with long-term mortality, cardiac death, and heart failure-related hospitalizations.We conducted a systematic review and meta-analysis of observational studies reporting Kaplan-Meier time-to-event data in patients with and without mitral PPM.Sixteen studies including 10,872 patients were analyzed.The pooled prevalence of any mitral PPM was 43% (95% CI, 29-59%), with significant heterogeneity (I = 100%).All-cause mortality was higher with PPM (HR, 1.32; 95% CI, 1.20-1.45;P<0.001; RMST difference, -3.35 years; 95% CI, -3.98 to -2.71; P<0.001), as was cardiac mortality (HR, 1.96; 95% CI, 1.54-2.51;P<0.001) and risk of heart failure hospitalization (HR, 2.82; 95% CI, 1.86-4.29;P<0.001).Risk-adjusted analyses confirmed these associations for all-cause and cardiac mortality.Severity-stratified analyses demonstrated a gradient effect: moderate PPM showed a trend toward higher mortality (HR, 1.12; 95% CI, 0.98-1.27;P=0.08), whereas severe PPM significantly increased mortality risk (HR, 1.36; 95% CI, 1.15-1.60;P<0.001).Sensitivity analyses according to PPM quantification method (in vivo vs. Doppler) and leave-one-out testing confirmed the robustness of the results.In conclusion, mitral PPM is common and independently associated with increased long-term all-cause mortality, cardiac death, and heart failure hospitalizations after MVR, with a dose-response relationship according to PPM severity.These findings highlight the importance of preventive strategies to avoid PPM when planning mitral valve replacement.