Abstract Body (Do not enter title and authors here): Background:
Prosthesis–patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) is most often evaluated using the measured indexed effective orifice area (EOAi) obtained from post-procedural echocardiography. However, this approach is subject to technical variability, operator dependence, and confounding by flow conditions, potentially limiting its reliability and clinical applicability. As a result, predicted PPM, using EOAi reference values specific to valve model and size, indexed to patient body surface area, has emerged as a more standardized, flow-independent alternative. Despite its growing use in TAVR research and procedural planning, the clinical significance of predicted PPM, particularly its association with long-term outcomes such as all-cause mortality, remains unclear.

Objectives:
To synthesize current evidence and evaluate the association between predicted PPM and all-cause mortality after TAVR through a systematic meta-analysis of published cohort studies.

Methods:
Six cohort studies comprising over 50,000 patients were included. Predicted prosthesis–patient mismatch (PPM) was defined using indexed effective orifice area (EOAi), calculated from prosthesis-specific reference values divided by body surface area. The presence of PPM was defined as EOAi < 0.85 cm2/m2, or < 0.70 cm2/m2 in patients with body mass index ≥30 kg/m2. Hazard ratios (HRs) for all-cause mortality comparing patients with vs. without PPM were pooled using a random-effects model. Between-study heterogeneity was assessed using the I2 statistic, and a 95% prediction interval was calculated.

Results:
A random-effects meta-analysis of six studies with follow-up durations ranging from approximately 1 to 5 years yielded a pooled hazard ratio of 1.01 [95% CI: 0.92–1.10], indicating no significant association between the exposure and the outcome. Between-study heterogeneity was low (I2 = 3.7%), and the prediction interval [0.88–1.15] suggests consistent findings across comparable future studies.

Conclusion:
Predicted PPM is not significantly associated with all-cause mortality following TAVR. These results question the clinical utility of predicted EOAi thresholds as a standalone metric in prosthesis selection. Overreliance on predicted PPM may unnecessarily limit device choice without improving patient outcomes. An individualized, anatomy-guided planning may better support optimal results in the evolving TAVR landscape.