Aims Prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) leads to increased mortality. However, its peri-procedural determinants remain unknown. We investigated geometric changes in aortic annulus (AoA) and left ventricular outflow tract (LVOT) during TAVR by three-dimensional transoesophageal echocardiography (3D-TEE) and its association with post-procedural PPM. Methods and results A total of 131 patients with severe aortic stenosis underwent intraprocedural

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... D-TEE during balloon-expandable TAVR. The severity of PPM was graded using the indexed effective orifice area calculated by Doppler echocardiography at discharge, with moderate defined as ≥0.65 and ≤0.85 cm 2 /m 2 and severe defined as ,0.65 cm 2 /m 2 . 3D planimetered AoA area decreased after TAVR (P , 0.001), whereas the LVOT increased (P ¼ 0.004). The eccentricity of both AoA and LVOT decreased after TAVR (both, P , 0.001). At discharge, the incidence of overall and severe PPM was 44 and 12%, respectively. Patients with PPM had a larger body surface area, smaller aortic valve area, and less frequent balloon dilation (all P , 0.05). Patients with PPM had a lower post-TAVR AoA area/pre-TAVR AoA area (91 + 8 vs. 95 + 7%, P ¼ 0.001) than those without PPM. The post-TAVR AoA area/pre-TAVR AoA area was independently associated with overall PPM (odds ratio, 1.80; 95% CI, 1.06-3.05; P ¼ 0.031) and severe PPM (odds ratio, 2.50; 95% CI, 1.05 -5.36; P ¼ 0.04). Additionally, a cut-off value of this ratio .86.3% had a sensitivity of 84% and a specificity of 44% for the prevention of severe PPM. Conclusion 3D-TEE can evaluate geometric changes in AoA and LVOT during balloon-expandable TAVR and predicts postprocedural PPM. ---