Sex-related differences in prosthesis-patient mismatch after surgical aortic valve replacement and long-term outcomes.

Summary

In 7,319 surgical AVR patients (median follow-up 12.6 years), PPM was more prevalent in women (31.9% vs 19.7%) and associated with higher all-cause (HR 1.30) and cardiovascular mortality (HR 1.39). After adjustment, VARC-3 PPM remained independently associated with outcomes only in women, while sex-specific spline-derived EOAi thresholds linked PPM with outcomes in both sexes.

Key Findings

• PPM was more prevalent in women vs men (31.9% vs 19.7%, P<0.0001); severe PPM was rare but more frequent in women (2.4% vs 0.6%).
• PPM associated with all-cause mortality (HR 1.30, 95% CI 1.20-1.40) and cardiovascular mortality (HR 1.39, 95% CI 1.23-1.57).
• After multivariable adjustment, VARC-3 PPM remained independently associated with outcomes only in women.
• Spline-derived sex-specific EOAi thresholds linked PPM with outcomes in both sexes, suggesting higher thresholds may be needed in men.

Clinical Implications

Surgeons should consider sex-specific EOAi thresholds to minimize PPM risk, particularly in women. Preoperative planning and prosthesis selection may change to achieve better effective orifice matching and outcomes.

Limitations

• Observational design with potential residual confounding.
• Single regional health system; external generalizability needs validation.

Future Directions

External validation of sex-specific EOAi thresholds across diverse populations and integration into surgical planning tools; assess impact on reoperation, symptoms, and quality of life.