Abstract: Background. Observational data suggest that early- and long-term outcomes of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) differ significantly between men and women, but have demonstrated conflicting results. This study sought to examine early- and long-term mortality with TAVR and SAVR in women versus men. Methods. Electronic search was performed until February 2018 for studies reporting sex-specific mortality following TAVR or isolated SAVR. Data were pooled using random-effects models. Outcomes included rates of early mortality (in hospital or 30 days) and long term (1 year or longer). Results. With 35 studies, a total of 80,928 patients were included in our systematic review and meta-analysis, including 40,861 men and 40,067 women. Pooled analyses suggested considerable sex-related differences in long-term mortality following TAVR and SAVR. Following SAVR, women had higher long-term mortality (odds ratio [OR], 1.35; 95% confidence interval [CI], 1.16-1.56; P<.001) and a trend toward higher early mortality (OR, 1.69; 95% CI, 0.97-2.97; P=.07) compared to men. Following TAVR, women had lower long-term mortality (OR, 0.78; 95% CI, 0.71-0.86; P<.001) and no difference in early mortality (OR, 1.09; 95% CI, 0.96-1.23; P=.17) compared to men. Conclusions. In this systematic review and meta-analysis, women had higher long-term mortality and a trend toward higher early mortality compared to men following SAVR. Following TAVR, women had lower long-term mortality and no difference in early mortality compared with men.
J INVASIVE CARDIOL 2020;32(8):295-301. Epub 2020 March 20.
Key words: long-term mortality, surgical risk
Symptomatic aortic stenosis (AS) is a common valvular heart disease that leads to a high rate of death if left untreated.1 Transcatheter aortic valve replacement (TAVR) is the standard of care to treat patients with AS who are at high or prohibitive risk for surgical aortic valve replacement (SAVR).2,3 More recently, low and intermediate surgical risk patients have been undergoing TAVR as well.4,5 Several studies have reported sex-specific incidence of morbidity and mortality after both TAVR and SAVR, but their results have been inconsistent. Consequently, the association between sex and early-, intermediate-, and late-term mortality in adults undergoing TAVR and SAVR remains unclear. Given the equipoise surrounding this issue, we conducted an updated and comprehensive systematic review and meta-analysis of all published studies to specifically investigate the difference in early, intermediate, and late mortality in men and women undergoing TAVR or SAVR.
Data searches. We report this systematic review in accordance with the Preferred Reporting of Items for Systematic reviews and Meta-Analyses (PRISMA) statement. We systematically searched Medline and Cochrane Database of Systematic Reviews from inception to February 19, 2018 for randomized trials and observational studies examining the relationship between sex and mortality in adults following TAVR or SAVR. The following search strategy was used: (aortic valve replacement or aortic valve intervention or aortic valve surgery) and (male or female or men or women or sex or gender) and (death or mortality or survival or outcomes). In addition, reference lists of pertinent articles were screened for potentially relevant citations missed by electronic searches. All study designs (prospective observational, retrospective, randomized controlled trials, and registries) were included.
Study selection. Studies were initially screened at the level of title and abstract, and then full-length reports were retrieved for detailed evaluation. Two authors (PBP, TYW) independently selected articles according to prespecified inclusion and exclusion criteria. Any discrepancy was resolved by consensus of the authors. Articles were included if they reported the number, incidence, or summary estimates for all-cause death for men and women separately undergoing TAVR or isolated SAVR. We restricted our analysis to published data. Abstracts and reviews were excluded, as were articles published in languages other than English.
Data extraction. Independently and in duplicate, two authors (PBP, TYW) extracted data. A table was designed to record data of eligible studies on the year of publication, study period, study type, risk score, number of men and women, access type (for TAVR studies), prosthetic valve type, follow-up duration, and mortality data. Mortality included all-cause mortality at early term (in hospital or 30 day) or long term (1 year or longer).
Statistical analysis. Because individual patient-level data from each study were not available, a meta-analysis of summary statistics from individual studies was performed using Comprehensive Meta-Analysis software, version 3 (Biostat, Inc). The association between sex and mortality was presented as an odds ratio (OR) with 95% confidence interval (CI) by applying the random-effects model.
The presence of statistically significant heterogeneity was assessed by the Q statistic (significant at P < .10), and the extent of any observed heterogeneity was determined by I2 (ranging from 0% to 100%). When between-study heterogeneity existed, we performed random-effects meta-analysis. Since the absence of statistical heterogeneity does not guarantee clinical homogeneity, summary ORs for all endpoints were calculated using a random-effects model from the ORs and 95% CIs for mortality in each study. The random-effects model provides a more conservative summary estimate because it incorporates both within-trial and between-trial variance. A P-value < .05 was considered statistically significant, and all tests were 2-sided unless otherwise indicated. To qualitatively assess publication bias, a funnel plot of the logarithm of effect size vs the standard error for each trial was generated. The Egger weighted linear regression test was used to examine the quantitative association between mean effect estimate and its variance.
Literature search and study selection. The process of study selection is illustrated in Figure 1. There were 8299 citations after removing duplicates. A total of 8177 citations were excluded as the titles and/or abstracts were not relevant to the proposed study. The remaining 122 articles were examined in greater detail for relevance. Fourteen of these citations were excluded due to absence of data on (or summary-estimates for) early- or long-term sex-specific mortality. Another 25 citations were excluded as these were either review articles, meta-analyses, or editorials. Forty-seven citations were excluded due to inappropriate study populations. A total of 35 articles were eligible for systematic review and meta-analysis, with 28 studies on TAVR6-33 and 7 studies on SAVR.34-40
Study, patient, and procedural characteristics. The characteristics of the included studies are presented in Table 1 and Table 2. The 28 TAVR studies6-33 and 7 SAVR studies34-40 included 80,928 adults (40,861 men and 40,067 women) for the comparison of sex-related differences in mortality after TAVR or SAVR.
Association between sex and mortality in TAVR. The association between sex and early- and long-term mortality following TAVR was quantitatively assessed in 266-15,17-27,29-33 and 19 studies,7,9-18,20-22,24,26,27,29,30,32,33 respectively. For studies in which 30-day mortality was not available,11,15,29,31,34,35 in-hospital mortality was utilized instead.The pooled results demonstrated that following TAVR, men had higher long-term mortality (OR, 1.28; 95% CI, 1.16-1.40; P<.001) and no difference in early mortality (OR, 0.92; 95% CI, 0.81-1.04; P=.17) compared with women (Figures 2A and 2B).
Association between sex and mortality in SAVR. The association between sex and early- and long-term mortality following SAVR was quantitatively assessed in 6 studies34-36,38-40 and 4 studies,34,36-38 respectively. The pooled results demonstrated that following SAVR, men had lower long-term mortality (OR, 0.74; 95% CI, 0.64-0.86; P<.001) and a trend toward lower early mortality (OR, 0.59; 95% CI, 0.34-1.03; P=.07) compared with women (Figures 3A and 3B).
The funnel plots for each analysis (Figures 4A and 4B) were symmetric, suggestive of a lack of publication bias.
The principal findings of this systematic review and meta-analysis of all published randomized and observational studies examining the relationship between sex and mortality in adults following TAVR or SAVR are: (1) men had lower long-term mortality following SAVR compared with women; (2) men had higher long-term mortality following TAVR compared with women; and (3) there was no difference in early mortality following SAVR or TAVR in men and women. These findings are unique in that this is the first meta-analysis to our knowledge to address sex-specific disparities in early- and long-term mortality with SAVR. It is also one of the largest studies to date addressing early- and long-term mortality in women vs men undergoing TAVR.
Sex-related differences in left ventricular adaptation to AS exist, with ventricular dysfunction being more common in men.41 Furthermore, the increased left ventricular wall thickness and smaller left ventricular systolic cavities with narrow outflow tracts seen in women have been associated with increased early mortality and morbidity in women following aortic valve replacement.42-45 Sex-specific pathophysiologic responses to pressure overload caused by AS exists, as it has been reported that women show a tendency toward greater ventricular hypertrophy despite equal transvalvular gradients41 and female sex has been independently associated with recovery of left ventricular ejection fraction following aortic valve replacement.45 Women also are more likely to receive smaller prosthetic valves, more frequently undergo aortic annular enlargement procedures, have greater technical difficulty associated with smaller anatomy, and have more bleeding complications related to cardiopulmonary bypass (ie, transfusion requirements).46,47
More recent data have emerged demonstrating improved outcomes in women following TAVR.29,39,48-50 Using data from the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry, Chandrasekhar et al demonstrated no difference between in-hospital mortality in men and women following TAVR but significantly lower 1-year mortality in women vs men,29 results that were confirmed in a recent meta-analysis by Saad et al.72 A patient-level meta-analysis by O’Connor et al noted similar 30-day mortality between men and women following TAVR but better long-term survival in women.48 Subgroup analyses from the Placement of Aortic Transcatheter Valves (PARTNER) trial and the CoreValve US Pivotal trial also demonstrated improved 1-year outcomes in women following TAVR compared with SAVR.39,49
Poor outcomes associated with prosthesis-patient mismatch (PPM) for SAVR have been well described in prior studies.51-53 It has been suggested that women experience PPM more frequently than men due to smaller valve sizes in women.54 While TAVR has been shown to have lower PPM rates than SAVR,52 reports of poor outcomes with PPM after balloon-expandable and self-expanding TAVR52,55 suggest that avoiding PPM may be an important variable in preprocedural planning.56 Many studies have investigated the impact of sex on postimplantation PPM, and although there was a trend toward higher rates of PPM among women in one study,57 most studies have shown that women do not appear to be at increased risk of this complication despite the frequent need for smaller valves.58-60 TAVR may seem to be a preferred modality in women who are surgical candidates but have smaller annular dimensions, given the lower incidence of postprocedural PPM compared with surgery.61 Future studies directly comparing TAVR vs SAVR specifically in this cohort with small aortic annuli to assess the possible impact of PPM on long-term clinical outcomes are warranted.
Study limitations. The current study is the largest analysis providing sex-specific outcomes of early- and late-term mortality in men and women following TAVR or SAVR. Our meta-analysis, however, should be interpreted within the context of several limitations. First, the included studies are primarily observational and so unmeasurable confounders may have affected the results. Second, there was significant heterogeneity between studies with respect to the study population (ie, surgical risk), TAVR access, and TAVR or SAVR valve type. Third, although great care was taken in selecting studies, the possibility of duplicated data synthesis as a result of their overlap in the patients enrolled cannot be completely ruled out. Finally, the lack of patient-level data precluded a more robust analysis.
In this systematic review and meta-analysis, women had higher long-term mortality following SAVR and lower long-term mortality following TAVR when compared with men. There was no significant difference in short-term outcomes following TAVR or SAVR. This is the largest study to date of sex-specific differences in early- and long-term mortality in men and women undergoing TAVR and the only study to date examining sex disparities in early- and long-term mortality in patients undergoing SAVR.
From the 1Division of Cardiovascular Medicine, Department of Medicine, State University of New York at Stony Brook, Stony Brook, New York; 2Division of Cardio- thoracic Surgery, State University of New York at Stony Brook, Stony Brook, New York; 3Division of Cardiothoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.
Disclosure: The authors have completed and returned the ICMJE Form for Dis- closure of Potential Conflicts of Interest. Dr Parikh reports consultant fees from Medtronic; scientific advisory board for AstraZeneca. Dr Jeremias reports con- sultant fees from Philips, Abbott, Boston Scientific, and Acist, Dr Butler reports consultant fees from Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Mayers Squib, CVRx, G3 Pharmaceutical, Janssen, Luitpold, Medtronic, Merck, Novartis, and Vifor. Dr Chikwe reports honoraria and fees to her institution from Edwards Lifesciences and Medtronic for speaker and consulting activities. The remaining authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 15, 2019, provisional acceptance given September 24, 2019, final version accepted October 2, 2019.
Address for correspondence: Puja B. Parikh, MD, MPH, FACC, FAHA, FSCAI, Medical Director, Transcatheter Aortic Valve Replacement Program, Assistant Professor, Department of Medicine, Stony Brook University Medical Center, Health Sciences Center T16-080, Stony Brook, NY 11794. Email: puja.parikh@ stonybrookmedicine.edu
- Ross J Jr, Braunwald E. Aortic stenosis. Circulation. 1968;38:61-67.
- Leon MB, Smith CR, Mack M, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597-1607.
- Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187-2198.
- Leon MB, Smith CR, Mack MJ, et al. Transcatheter or surgical aortic-valve replacement in Intermediate-risk patients. N Engl J Med. 2016;374:1609-1620.
- Reardon MJ, Van Mieghem NM, Popma JJ, et al; for the SURTAVI Investigators. Surgical or transcatheter aortic-valve replacement in intermediate-risk patients. N Engl J Med. 2017;376:1321-1331.
- Buchanan GL, Chieffo A, Montorfano M, et al. The role of sex on VARC outcomes following transcatheter aortic valve implantation with both Edwards Sapien™ and Medtronic CoreValve ReValving System® devices: the Milan registry. EuroIntervention. 2011;7:556-563.
- Humphries KH, Toggweiler S, Rodes-Cabau J, et al. Sex differences in mortality after transcatheter aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2012;60:882-886.
- Hayashida K, Morice MC, Chevalier B, et al. Sex-related differences in clinical presentation and outcome of transcatheter aortic valve implantation for severe aortic stenosis. J Am Coll Cardiol. 2012;59:566-571.
- Finkelstein A, Havakuk O, Steinvil A, et al. Gender differences and clinical outcome in patients undergoing trans-femoral aortic valve implantation. Int J Cardiol. 2013;168:4854-4855.
- Diemert P, Seiffert M, Schnabel R, et al. Patient gender does not affect outcome after transcatheter aortic valve implantation (TAVI). J Heart Valve Dis. 2013;22:789-793.
- Buja P, Napodano M, Tamburino C, et al. Comparison of variables in men versus women undergoing transcatheter aortic valve implantation for severe aortic stenosis (from Italian Multicenter CoreValve registry). Am J Cardiol. 2013;111:88-93.
- D’Ascenzo F, Gonella A, Moretti C, et al. Gender differences in patients undergoing TAVI: a multicentre study. EuroIntervention. 2013;9:367-372.
- Al-Lamee R, Broyd C, Parker J, et al. Influence of gender on clinical outcomes following transcatheter aortic valve implantation from the UK transcatheter aortic valve implantation registry and the National Institute for Cardiovascular Outcomes Research. Am J Cardiol. 2014;113:522-528.
- Erez A, Segev A, Medvedofsky D, et al. Factors affecting survival in men versus women following transcatheter aortic valve implantation. Am J Cardiol. 2014;113:701-705.
- Sherif MA, Zahn R, Gerckens U, et al. Effect of gender differences on 1-year mortality after transcatheter aortic valve implantation for severe aortic stenosis: results from a multicenter real-world registry. Clin Res Cardiol. 2014;103:613-620.
- Ferrante G, Pagnotta P, Petronio AS, et al. Sex differences in postprocedural aortic regurgitation and mid-term mortality after transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2014;84:264-271.
- Conrotto F, D’Ascenzo F, Salizzoni S, et al. A gender based analysis of predictors of all cause death after transcatheter aortic valve implantation. Am J Cardiol. 2014;114:1269-1274.
- Madershahian N, Scherner M, Rudolph T, et al. Impact of sex on the risk to develop contrast-induced nephropathy after transcatheter aortic valve implantation. Innovations (Phila). 2014;9:87-92.
- Onorati F, D’Errigo P, Barbanti M, et al. Different impact of sex on baseline characteristics and major periprocedural outcomes of transcatheter and surgical aortic valve interventions: results of the multicenter Italian OBSERVANT registry. J Thorac Cardiovasc Surg. 2014;147:1529-1539.
- Biere L, Launay M, Pinaud F, et al. Influence of sex on mortality and perioperative outcomes in patients undergoing TAVR: insights from the FRANCE 2 registry. J Am Coll Cardiol. 2015;65:755-757.
- Forrest JK, Adams DH, Popma JJ, et al. Transcatheter aortic valve replacement in women versus men (from the US CoreValve trials). Am J Cardiol. 2016;118:396-402.
- Kodali S, Williams MR, Doshi D, et al. Sex-specific differences at presentation and outcomes among patients undergoing transcatheter aortic valve replacement: a cohort study. Ann Intern Med. 2016;164:377-384.
- Asgar A, Chandrasekhar J, Mikhail G, et al. Sex-based differences in outcomes with bivalirudin or unfractionated heparin for transcatheter aortic valve replacement: results from the BRAVO-3 randomized trial. Catheter Cardiovasc Interv. 2017;89:144-153.
- Gaglia MA Jr, Lipinski MJ, Torguson R, et al. Comparison in men versus women of co-morbidities, complications, and outcomes after transcatheter aortic valve implantation for severe aortic stenosis. Am J Cardiol. 2016;118:1692-1697.
- Katz M, Carlos Bacelar Nunes Filho A, Caixeta A, et al. Gender-related differences on short- and long-term outcomes of patients undergoing transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2017;89:429-436.
- Czarnecki A, Qiu F, Koh M, et al. Clinical outcomes after trans-catheter aortic valve replacement in men and women in Ontario, Canada. Catheter Cardiovasc Interv. 2017;90:486-494.
- Bauer T, Mollmann H, Beckmann A, et al. Left ventricular function determines the survival benefit for women over men after transcatheter aortic valve implantation (TAVI). EuroIntervention. 2017;13:467-474.
- Levi A, Landes U, Assali AR, et al. Long-term outcomes of 560 consecutive patients treated with transcatheter aortic valve implantation and propensity score-matched analysis of early- versus new-generation valves. Am J Cardiol. 2017;119:1821-1831.
- Chandrasekhar J, Dangas G, Yu J, et al. Sex-based differences in outcomes with transcatheter aortic valve therapy: TVT registry from 2011 to 2014. J Am Coll Cardiol. 2016;68:2733-2744.
- Bagienski M, Tokarek T, Wiktorowicz A, et al. Sex-related differences in clinical outcomes and quality of life after transcatheter aortic valve implantation for severe aortic stenosis. Postepy Kardiol Interwencyjnej. 2017;13:233-239.
- Doshi R, Shlofmitz E, Meraj P. Comparison of outcomes and complications of transcatheter aortic valve implantation in women versus men (from the National Inpatient Sample). Am J Cardiol. 2018;121:73-77.
- Szerlip M, Gualano S, Holper E, et al. Sex-specific outcomes of transcatheter aortic valve replacement with the Sapien 3 valve: insights from the PARTNER II S3 high-risk and intermediate-risk cohorts. JACC Cardiovasc Interv. 2018;11:13-20.
- Sannino A, Szerlip M, Harrington K, Schiattarella GG, Grayburn PA. Comparison of baseline characteristics and outcomes in men versus women with aortic stenosis undergoing transcatheter aortic valve implantation. Am J Cardiol. 2018;121:844-849.
- Milavetz DL, Hayes SN, Weston SA, Seward JB, Mullany CJ, Roger VL. Sex differences in left ventricular geometry in aortic stenosis: impact on outcome. Chest. 2000;117:1094-1099.
- Duncan AI, Lin J, Koch CG, Gillinov AM, Xu M, Starr NJ. The impact of gender on in-hospital mortality and morbidity after isolated aortic valve replacement. Anesth Analg. 2006;103:800-808.
- Saxena A, Dinh DT, Smith JA, Reid CM, Shardey GC, Newcomb AE. Females do not have increased risk of early or late mortality after isolated aortic valve replacement: results from a multi-institutional Australian study. J Cardiovasc Surg (Torino). 2013;54:297-303.
- Petrov G, Dworatzek E, Schulze TM, et al. Maladaptive remodeling is associated with impaired survival in women but not in men after aortic valve replacement. JACC Cardiovasc Imaging. 2014;7:1073-1080.
- Elhmidi Y, Piazza N, Mazzitelli D, Wottke M, Lange R, Bleiziffer S. Sex-related differences in 2197 patients undergoing isolated surgical aortic valve replacement. J Card Surg. 214;29:772-778.
- Williams M, Kodali SK, Hahn RT, et al. Sex-related differences in outcomes after transcatheter or surgical aortic valve replacement in patients with severe aortic stenosis: insights from the PARTNER trial (placement of aortic transcatheter valve). J Am Coll Cardiol. 2014;63:1522-1528.
- Heinze G, Christ T, Leonards CO, Dohmen PM, Konertz W. Risk and outcome of aortic valve surgery in the transcatheter valve era: the gender aspect. Ann Thorac Cardiovasc Surg. 2015;21:446-451.
- Carroll JD, Carroll EP, Feldman T, et al. Sex-associated differences in left ventricular function in aortic stenosis of the elderly. Circulation. 1992;86:1099-1107.
- Aurigemma G, Battista S, Orsinelli D, Sweeney A, Pape L, Cuenoud H. Abnormal left ventricular intracavitary flow acceleration in patients undergoing aortic valve replacement for aortic stenosis. A marker for high postoperative morbidity and mortality. Circulation. 1992;86:926-936.
- Orsinelli DA, Aurigemma GP, Battista S, Krendel S, Gaasch WH. Left ventricular hypertrophy and mortality after aortic valve replacement for aortic stenosis. A high risk subgroup identified by preoperative relative wall thickness. J Am Coll Cardiol. 1993;22:1679-1683.
- Wiseth R, Skjaerpe T, Hatle L. Rapid systolic intraventricular velocities after valve replacement for aortic stenosis. Am J Cardiol. 1993;71:944-948.
- Morris JJ, Schaff HV, Mullany CJ, et al. Determinants of survival and recovery of left ventricular function after aortic valve replacement. Ann Thorac Surg. 1993;56:22-30.
- Morris JJ, Schaff HV, Mullany CJ, Morris PB, Frye RL, Orszulak TA. Gender differences in left ventricular functional response to aortic valve replacement. Circulation. 1994;90:183-189.
- Blackstone EH, Cosgrove DM, Jamieson WR, et al. Prosthesis size and long-term survival after aortic valve replacement. J Thorac Cardiovasc Surg. 2003;126:783-796.
- O’Connor SA, Morice MC, Gilard M, et al. Revisiting sex equality with transcatheter aortic valve replacement outcomes: a collaborative, patient-level meta-analysis of 11,310 patients. J Am Coll Cardiol. 2015;66:221-228.
- Skelding KA, Yakubov SJ, Kleiman NS, et al. Transcatheter aortic valve replacement versus surgery in women at high risk for surgical aortic valve replacement (from the CoreValve US high risk pivotal trial). Am J Cardiol. 2016;118:560-566.
- Saad M, Nairooz R, Pothineni NVK, et al. Long-term outcomes with transcatheter aortic valve replacement in women compared with men: evidence from a meta-analysis. JACC Cardiovasc Interv. 2018;11:24-35.
- Hahn RT, Pibarot P, Stewart WJ, et al. Comparison of transcatheter and surgical aortic valve replacement in severe aortic stenosis: a longitudinal study of echocardiography parameters in cohort A of the PARTNER trial (placement of aortic transcatheter valves). J Am Coll Cardiol. 2013;61:2514-2521.
- Pibarot P, Weissman NJ, Stewart WJ, et al. Incidence and sequelae of prosthesis-patient mismatch in transcatheter versus surgical valve replacement in high-risk patients with severe aortic stenosis: a PARTNER trial cohort — a analysis. J Am Coll Cardiol 2014;64:1323-1334.
- Head SJ, Mokhles MM, Osnabrugge RL, et al. The impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement: a systematic review and meta-analysis of 34 observational studies comprising 27,186 patients with 133,141 patient-years. Eur Heart J. 2012;33:1518-1529.
- Bonderman D, Graf A, Kammerlander AA, et al. Factors determining patient-prosthesis mismatch after aortic valve replacement — a prospective cohort study. PLoS One. 2013;8:e81940.
- Popma JJ, Khabbaz K. Prosthesis-patient mismatch after “high-risk” aortic valve replacement. J Am Coll Cardiol. 2014;64:1335-1338.
- Hahn RT, Leipsic J, Douglas PS, et al. Comprehensive echocardiographic assessment of normal transcatheter valve function. JACC Cardiovasc Imaging. 2019;12:25-34.
- Kukucka M, Pasic M, Dreysse S, et al. Patient-prosthesis mismatch after transapical aortic valve implantation: incidence and impact on survival. J Thorac Cardiovasc Surg. 2013;145:391-397.
- Bleiziffer S, Hettich I, Hutter A, et al. Incidence and impact of prosthesis-patient mismatch after transcatheter aortic valve implantation. J Heart Valve Dis. 2013;22:309-316.
- Jilaihawi H, Chin D, Spyt T, et al. Prosthesis-patient mismatch after transcatheter aortic valve implantation with the Medtronic-CoreValve bioprosthesis. Eur Heart J. 2010;31:857-864.
- Ewe SH, Muratori M, Delgado V, et al. Hemodynamic and clinical impact of prosthesis-patient mismatch after transcatheter aortic valve implantation. J Am Coll Cardiol. 2011;58:1910-1918.
- Kalavrouziotis D, Rodes-Cabau J, Bagur R, et al. Transcatheter aortic valve implantation in patients with severe aortic stenosis and small aortic annulus. J Am Coll Cardiol. 2011;58:1016-1024.