Letter to the Editor Response

We thank Dr. Shah for their comments on our work.Consistent with Valve Academic Research Consortium 3 guidelines, the diagnosis of prosthesis-patient mismatch (PPM) was based on indexed effective orifice area derived from transthoracic echocardiography using body mass index-specific criteria, rather than transvalvular pressure gradients. 1Although calculated indexed effective orifice area can be flow dependent and may overestimate the incidence of PPM in low-flow states, 2,3 current guidelines do not endorse stroke volume-based cutoffs for defining PPM. 1 Indeed, echocardiographic assessment of prosthetic valve function is subject to significant variability, depending on flow state, annulus anatomy, calcification burden, valve type and position, and prosthesis geometry.The outcome of hemodynamic valve deterioration (HVD) relied on post-implant mean gradients.However, the Valve Academic Research Consortium 3 criteria for HVD require a significant increase in the mean gradient from the post-transcatheter aortic valve replacement (TAVR) baseline, mitigating the effects of a chronic high-flow state.Furthermore, all HVD events were manually adjudicated with the electronic medical record and correlated with clinically significant bioprosthetic valve failure.Of the 33 total valve-in-valve cases, 30 (90.9%) were for failed surgical bioprostheses and 3 (9.1%)were for failed TAVR valves.Bioprosthetic valve fracture was attempted and successfully achieved in 1 patient.Balloon pre-dilation was performed in 5 (15.2%) valve-in-valve cases and post-dilation was performed in 4 (12.1%)cases.Analogous to the referenced surgical literature, PPM may impact TAVR valve longevity by inducing adverse hemodynamics, although further research is needed to elucidate this mechanism.In our cohort study, the association of PPM with HVD and bioprosthetic valve failure underscores its clinical relevance, warranting further study to identify effective strategies for PPM mitigation and prevention. 4e agree that formal investigation is needed to determine the optimal patient selection criteria and comparative efficacy of procedural techniques, including the choice of valve type, valve fracture, balloon dilation, or leaflet modification, in reducing residual gradients and minimizing PPM.Such work will be particularly relevant in the lifetime valve management strategy as TAVR and valve-in-valve procedural volumes increase across the age spectrum.