# Flow Status-Based Predicted Prosthesis-Patient Mismatch in Patients Undergoing Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve

## TL;DR

This study examines how considering blood flow status improves predictions of prosthesis-patient mismatch in heart valve replacement patients, finding that it doesn't increase risk of adverse events.

## Contribution

The study introduces a flow status-based method to predict prosthesis-patient mismatch, showing it reclassifies mismatch severity but does not increase risk.

## Key findings

- Flow status-based predicted PPM reclassifies mismatch severity compared to traditional methods.
- No increased risk of adverse events was found in patients with flow status-based predicted PPM over five years.
- Rates of PPM varied significantly depending on the assessment method used.

## Abstract

Effective orifice area (EOA) is flow dependent. However, established methods for the assessment of predicted prosthesis-patient mismatch (PPM) do not consider flow status and therefore may underestimate the rate and impact of PPM in patients with abnormal flow status. This study aimed to investigate the clinical impact of flow status-based predicted PPM in patients undergoing transcatheter aortic valve replacement (TAVR).

Patients undergoing TAVR in a prospective TAVR registry were stratified by the presence of moderate or severe PPM (EOA index to body surface area [EOAi]: 0.65-0.85 or ≤0.65 and 0.55-0.70 or ≤0.55 cm2/m2 if obese). PPM was defined according to echocardiographically measured EOAi (measured PPM) or predicted or flow status-based predicted EOAi. Predicted EOAs were based on reference values of EOA for each valve generation and size (predicted PPMTHV) or native aortic annulus dimension (predicted PPMCT).

Among 1510 patients included (August 2007-June 2022), rates of moderate or severe PPM differed according to method of assessment: 27.0 and 8.7% according to measured PPM, 11.3 and 1.2% according to predicted PPMTHV, 12.0 and 0.1% according to PPMCT, 21.6 and 0.2% according to flow status-based predicted PPMTHV, and 25.1 and 0.4% according to flow status-based predicted PPMCT. Five-year mortality was comparable in patients with and without flow status-based predicted PPM defined by either method. These results were consistent when patients were stratified by flow status.

Rates of PPM differ considerably when flow status is considered. There was no consistent signal of increased risk of adverse events up to 5 years in patients with flow status-based predicted PPM.

https://www.clinicaltrials.gov. NCT01368250.

•In the assessment of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement, the use of predicted vs. measured effective orifice area results in a lower estimate of PPM frequency.•Consideration of flow status significantly recategorized the severity of PPM.•Flow status-based predicted PPM was not associated with an increased risk of adverse events up to 5 years of follow-up irrespective of flow status.•Further studies are warranted to optimize accurate assessment of bioprosthetic hemodynamics and to evaluate the impact of PPM on long-term clinical outcomes after transcatheter aortic valve replacement.

In the assessment of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement, the use of predicted vs. measured effective orifice area results in a lower estimate of PPM frequency.

Consideration of flow status significantly recategorized the severity of PPM.

Flow status-based predicted PPM was not associated with an increased risk of adverse events up to 5 years of follow-up irrespective of flow status.

Further studies are warranted to optimize accurate assessment of bioprosthetic hemodynamics and to evaluate the impact of PPM on long-term clinical outcomes after transcatheter aortic valve replacement.