Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Implantation: The Prognostic Effect of Right-sided cardiopulmonary Remodelling

BACKGROUND: Prosthesis-patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS) is associated with adverse outcomes. In this study we evaluated the prognostic effect of PPM after TAVI in relation to baseline right-sided cardiopulmonary remodelling. METHODS: Consecutive patients who underwent transfemoral TAVI for severe symptomatic AS between 2015 and 2022 were identified (n = 1118). PPM was defined at discharge according to Valve Academic Research Consortium-3 criteria. Baseline right-sided cardiopulmonary remodelling was defined as either right ventricular dysfunction (RVD: tricuspid annular plane systolic excursion < 17 mm) or pulmonary hypertension (PH: pulmonary arterial systolic pressure ≥ 60 mm Hg). We used multivariable Cox regression to identify independent predictors of all-cause mortality. RESULTS: Moderate and severe PPM were observed in 235 (21.0%) and 72 (6.4%) patients, respectively, and RVD and PH in 95 (8.5%) and 286 (26.0%) patients, respectively. Moderate (adjusted hazard ratio aHR, 1.42; 95% confidence interval CI, 1.15-1.76; P < 0.001) and severe (aHR, 5.94; 95% CI, 4.45-7.94; P < 0.001) PPM were independently associated with all-cause mortality. In patients with moderate and severe PPM, PH (aHR, 1.48; 95% CI, 1.08-2.03; P = 0.014) and RVD (aHR, 2.14; 95% CI, 1.07-4.29; P = 0.033) were significant and independent predictors of all-cause mortality. In patients with baseline RVD/PH, severe PPM (aHR, 4.75; 95% CI, 3.20-7.04; P < 0.001) remained significantly and independently associated with all-cause mortality. CONCLUSIONS: PPM is associated with increased risk of mortality after TAVI, particularly in patients with preexisting right-sided cardiopulmonary remodelling. These results support the need for improved detection and prevention of PPM after TAVI, especially in vulnerable subgroups of AS patients with RVD/PH.