A Multi-Institutional Study on the Prevalence and Clinical Impact of Patient-Prosthesis Mismatch in Surgical Aortic Valve Replacement

Abstract

Background: Prosthesis-patient mismatch (PPM) impacts surgical aortic valve replacement outcomes, with known associations with adverse clinical consequences. However, contemporary understanding of PPM's clinical implications, trends, and predictive factors remains limited.

Methods: This multi-institutional study included all patients undergoing surgical aortic valve replacement between 2002 and 2023. PPM was calculated using effective orifice area indexed to body surface area (EOAi), categorized as moderate (EOAi ≤0.85 cm²/m²) or severe (EOAi ≤0.65 cm²/m²), with modified criteria for patients with body mass index ≥30 kg/m² according to Valve Academic Research Consortium 3 guidelines. Clinical outcomes and predictors were assessed using Kaplan-Meier and multivariable analysis.

Results: Among 10,607 surgical aortic valve replacement patients, 8102 (76%) had no PPM, 2333 (22%) had moderate PPM, and 172 (2%) had severe PPM. PPM prevalence declined over the last decade (31% to 18%, P < .05), coinciding with larger prosthetic valves (size 23 [SD, 2] mm to 24 [SD, 2] mm, P < .05) and increased annular enlargement (2.4% to 6.0%, P < .05). PPM was associated with higher 30-day mortality (odds ratio, 1.46; 95% CI 1.13-1.88; P < .05) and reduced long-term survival. Age- and sex-stratified analysis revealed a stronger association between advanced age and PPM risk in women compared with men (odds ratio, 2.31 vs 1.66 for age >74 vs <65 years; both P < .05).

Conclusions: PPM prevalence has declined through technical improvements and evolving patient selection but remains a significant predictor of adverse outcomes. The pronounced risk in older female patients highlights the need for targeted surgical strategies, including careful prosthesis selection and consideration of annular enlargement in high-risk groups.