I read with great interest the article, which evaluated the impact of body mass index (BMI) and valve size on post-procedural gradients following balloon-expandable transcatheter aortic valve replacement (TAVR) (1). The authors demonstrated that patients with higher BMI, particularly those receiving smaller valves, exhibited higher transvalvular gradients at 30 days. Several concerns have been raised.
The observed association between BMI and post-TAVR gradients may be strongly influenced by flow status. Higher BMI is generally associated with greater metabolic demand and cardiac output, potentially resulting in increased transvalvular flow and consequently higher Doppler-derived gradients despite similar prosthetic valve performance (2). It would therefore be informative to know whether stroke volume index, cardiac output, or Doppler velocity index differed among the study groups. Such analyses could help distinguish true prosthesis-related hemodynamic limitation from flow-dependent gradient elevation.
Patient-prosthesis mismatch (PPM) may represent an important mechanistic link between BMI and elevated gradients. Because body surface area was substantially greater in the high-BMI cohort (1), indexing effective orifice area to body surface area may have revealed a higher prevalence of moderate or severe PPM in these patients (3). Additional analyses incorporating indexed effective orifice area and PPM classification may clarify whether BMI itself independently affects gradients or primarily acts through increased risk of PPM.
Although the authors focused on 30-day hemodynamic findings (1), the clinical implications of these gradient differences remain uncertain. The absolute gradient values reported were relatively modest, and it is uncertain whether they translate into differences in symptoms (1), functional capacity, valve durability, structural valve deterioration, or long-term clinical outcomes (4). Future studies evaluating the prognostic significance of BMI-associated gradient elevation would be of great value.
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Acknowledgments
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Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Footnotes
Provenance and Peer Review: This article was a standard submission to the journal. The article did not undergo external peer review.
Funding: None.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2026-0295/coif). The author has no conflicts of interest to declare.
References
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