TAVI in Women: Patient-Prosthesis Mismatch Doesn’t Impact Long-Term Survival

Introduction
As transcatheter aortic valve implantation (TAVI) expands into younger and lower-risk populations, patient-prosthesis mismatch (PPM) remains a hot topic—particularly in women with smaller annuli. A new multicenter analysis presented at the SCAI 2025 Scientific Sessions offers a reassuring message: while women are more likely than men to develop PPM after TAVI, this does not translate into worse long-term survival.

This finding challenges traditional assumptions about PPM and underscores the need for nuanced, patient-centered valve selection—especially for female patients.

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Understanding PPM in the Context of TAVI
PPM occurs when the effective orifice area of the prosthetic valve is too small relative to the patient’s body size, potentially leading to higher gradients and adverse outcomes. While this is a known concern in surgical aortic valve replacement (SAVR), its implications in the TAVI era are more complex.

Key insights include:

• Women had higher rates of predicted and echocardiographically measured severe PPM than men:

  • Predicted severe PPM: 1.7% (women) vs. 0.1% (men)

  • Measured severe PPM: 7.3% (women) vs. 5.4% (men)

• Despite this, 5-year survival was unaffected by PPM severity in women.

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Study Details
A total of 3,016 TAVI patients (44% women, mean age 80) treated across six hospitals within the Baylor Scott & White Healthcare System (2012–2021) were retrospectively analyzed:

• Balloon-expandable valves (Edwards Sapien series) were used in 74% of patients.

• Women were more likely to experience moderate or severe PPM, especially with balloon-expandable devices.

Despite theoretical concerns, measured or predicted PPM had no significant impact on 5-year survival—even among women with higher mismatch rates.

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The Valve Type Question: Self-Expanding vs Balloon-Expandable
Interestingly, moderate PPM was more frequent with balloon-expandable valves:

• Predicted moderate PPM: 31.3% (balloon-expandable) vs. 8.2% (self-expanding)

• Measured moderate PPM: 22.9% vs. 11%, respectively

Yet, a slight survival trend was noted:

• Women with self-expanding valves and moderate PPM showed a lower unadjusted 5-year survival vs. those without PPM (P = 0.0230)

• After risk adjustment, this trend disappeared—likely due to the small sample size (only 26% had self-expanding valves).

The SMART trial and other studies suggest self-expanding valves may offer better hemodynamics in small annuli, making them a valuable option for women.

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Sex-Based Differences: Real-World vs Clinical Trials
A notable finding: men with PPM fared worse than women at 5 years, contradicting older assumptions and highlighting the role of sex-specific physiology and valve-patient interactions.

This emphasizes the need for real-world data to complement clinical trials, especially when making lifetime management decisions in aortic stenosis.

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Clinical Implications & Future Research Directions
Although PPM remains undesirable, this study suggests it may be less clinically impactful after TAVI—especially for women—than previously thought.

Key considerations:

• Individualized valve selection remains crucial.

• PPM should still be avoided when possible, but its presence may not mandate aggressive interventions in women.

• Ongoing trials comparing SAVR with root enlargement vs TAVI in women may further clarify optimal strategies.

As more low-risk and younger patients undergo TAVI, the long-term impact of PPM—and valve choice—will become increasingly relevant.

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Key Takeaways for Clinicians

• Women undergoing TAVI have higher rates of PPM, especially with balloon-expandable valves.

• Despite this, 5-year survival is unaffected, suggesting PPM after TAVI may not carry the same mortality risk as with SAVR.

• Self-expanding valves may reduce PPM incidence in women with small annuli but didn’t confer a clear long-term survival benefit in this study.

• Men may be more adversely affected by PPM than women, highlighting sex-based differences in outcomes.

• Real-world evidence continues to refine valve selection and lifetime planning in aortic stenosis.