Prosthesis‐Patient Mismatch in All‐Comer Patients Undergoing Newer‐Generation Self‐Expanding Transcatheter Aortic Valve Replacement

BACKGROUND: Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) may affect outcomes, but its incidence and impact with contemporary self-expanding valves remain unclear. AIMS: Evaluate the frequency, predictors, and long-term outcomes of PPM in a real-world TAVR population. METHODS: We analyzed patients ≥ 18 years undergoing TAVR with current-generation self-expanding valves (Evolut FX/FX+, PRO/PRO+, Navitor, Navitor Vision) from a prospectively maintained institutional database (2017-2025). Predicted PPM was defined according to VARC-3 criteria, with all-cause mortality and heart failure hospitalization as the primary outcomes. RESULTS: Among 2989 patients (median age 80 [75-85], 50.8% female) receiving Evolut (83.3%) or Navitor (16.7%) valves, PPM occurred in 5.0% (moderate 3.7%, severe 1.3%) and declined from 6.5% in 2017 to 2.7% in 2025 (p = 0.002). Independent predictors of PPM included female sex (OR 2.04, 95% CI 1.06-3.99, p = 0.035) and valve-in-valve procedures (OR 9.60, 95% CI 3.82-25.64, p < 0.001), whereas use of the Navitor valve was associated with markedly lower odds (OR 0.07, 95% CI 0.00-0.32, p = 0.009). Patients with PPM demonstrated significantly higher post-procedural transvalvular gradients and reduced aortic valve areas (both p < 0.001). PPM was not associated with adverse long-term clinical outcomes, with no significant differences in 5-year all-cause mortality (HR 0.84, 95% CI 0.45-1.57, p = 0.592) or heart failure hospitalization (HR 1.22, 95% CI 0.84-1.77, p = 0.295). CONCLUSION: In this contemporary TAVR cohort, PPM was infrequent, and its incidence declined over time. Female sex and valve-in-valve procedures independently predicted PPM. Despite adverse hemodynamic profiles, PPM was not associated with early or long-term adverse clinical outcomes.