Does prosthesis-patient mismatch impact long-term mortality differently in men and women after surgical aortic valve replacement?
Prosthesis-patient mismatch after surgical aortic valve replacement is more prevalent in women and requires sex-specific EOAi thresholds to accurately predict long-term mortality in both sexes.
BACKGROUND AND AIMS: Prosthesis-patient mismatch (PPM) is associated with dismal prognosis after aortic valve replacement (AVR). Sex differences in PPM outcomes remain poorly explored. Therefore, this study aims to evaluate sex-specific impact in PPM after surgical AVR. METHODS: Between 2000 and 2021, 7319 patients underwent surgical AVR at the Institut Universitaire de Cardiologie et de Pneumologie de Québec. Prosthesis-patient mismatch was defined by using the indexed effective orifice area (EOAi) and by applying the Valve Academic Research Consortium-3 (VARC-3) criteria. The cohort was followed up prospectively from surgical AVR until November 2023. The primary endpoint was defined as long-term mortality and the secondary endpoint as long-term cardiovascular (CV) and perioperative mortality. Mortality was established and CV mortality was adjudicated by Quebec national database. RESULTS: Any-degree PPM resulted more prevalent in women than in men (31.9% vs. 19.7%, P < .0001) with rare incidence of severe PPM (2.4% vs. 0.6%, P < .0001) according to VARC-3 definition. Over a median follow-up of 12.6 years, there were 3231 (44.1%) all-cause deaths, with 1238 (16.9%) from CV causes. Prosthesis-patient mismatch was associated with all-cause mortality (hazard ratio 1.30, 95% CI 1.20-1.40; P < .0001) and CV mortality (hazard ratio 1.39, 95% CI 1.23-1.57; P < .0001) in the whole cohort without interaction between sexes (P ≥ .74). After comprehensive multivariable adjustment, VARC-3 PPM remained independently associated with outcome only in women (P ≤ .04). Adapting PPM definition according to spline-derived EOAi thresholds disaggregated by sex, PPM was independently associated with outcome in both sexes (P ≤ .04). CONCLUSIONS: Sex-specific EOAi thresholds associated with outcomes emerged in this large regional study. This finding suggests that PPM definition in men may follow higher EOAi thresholds than in women.
Springhetti et al. (Wed,) studied this question.