Patient-prosthesis mismatch and strategies to prevent it during aortic valve replacement (original) (raw)
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ABC Imagem Cardiovascular, 2022
Introduction: Patient-prosthesis mismatch (PPM) is considered to occur if a prosthetic heart valve has a high transvalvular pressure gradient and a reduced indexed valve area, despite normally functioning discs. PPM may have clinical and hemodynamic repercussions for patients. Objective: To analyze the clinical and echocardiographic characteristics of PPM in patients with prosthetic aortic valves. Methods: Patients aged 18 years or over with a biological or mechanical aortic valve undergoing follow-up since February 2010 were included. PPM was considered mild if the indexed valve area was ≥ 0.85 cm 2 /m 2 and severe if ≤ 0.65 cm 2 /m 2. Variables were compared between groups with moderate or severe PPM (PPMAO2) and mild PPM (PPMAO1); significant if p<0.05. Results: Sixty patients (36 women) with prosthetic aortic valves (29 biological and 31 mechanical) were included. PPMAO2 was diagnosed in 12 patients (20%), who had a mean valve area of 0.66 cm²/m² and mean gradient of 24 mm Hg. Functional class II or III was more frequent in the PPMAO2 group (66.7%) than in the PPMAO1 group (20.8%); p<0.001. Left atrial volume (51 ± 16 mL/m 2 x 40 ± 12 mL/m 2 ; p=0.002) and left ventricular septal and wall thicknesses (10.83 mm x 10 mm; p=0.018) were higher in the PPMAO2 group. Conclusions: Moderate or severe PPM occurred in 20% of patients. These patients were more symptomatic and had higher left atrial volumes and left ventricular myocardial wall thickness.
2000
Most studies about prosthesis-patient mismatch (PPM) were conducted before the introduction of new high-performance prostheses. Nowadays, PPM could become unfrequent. Our aim was to study the impact of new prostheses on PPM in comparison with previous experience. Prosthetic Indexed Effective Orifice Area (EOAi) was estimated in two historical cohorts. Group A: 339 patients undergoing AVR from Mar 94-Nov 01. Group B: 404 operated on during the last three years when latest generation prostheses were implanted. Incidence, determinants of PPM and clinical results were studied. Moderate PPM (EOAi F0.85 cm ym ) was present in 38% and 19% (respective 2 2 groups). Mean EOAi increased from 1.02"0.29 cm ym to 1.11"0.27 cm ym . 'Group B' and 'new prostheses' were protective. Thirty-day 2 2 2 2 mortality was 3.8% and 4.7% with higher rate in patients with increased left ventricular mass index (LVMI), especially if PPM was present: 14.7 vs. 2.1% (P-0.05) in Group A; 25.0 vs. 4.8% (P-0.05) in Group B (PPM vs. no-PPM). LVMI regression was impaired in these patients. Moderate PPM was an independent predictor of late cardiac mortality (OR: 3.38, 95% CI: 1.37-8.31; P-0.01). PPM is a prognostic factor for late cardiac death. Its impact on early mortality is only relevant in patients with high LVMI. Its incidence has decreased with the use of new prostheses.
JACC: Cardiovascular Interventions, 2019
Objectives: To compare the frequency of PPM with self-expandable valves (SEV) to balloon-expandable valves (BEV). Background: Prosthesis-patient mismatch (PPM) has been associated with increased mortality after transcatheter aortic valve replacement. Data on the frequency of PPM as a function of supra-annular or intra-annular position of transcatheter heart valves is insufficient. Methods: A total of 757 patients treated with SEV (CoreValve, Evolut R) and BEV (SAPIEN THV/XT/3) were enrolled in the present analysis between August 2007 and June 2017. PPM was classified based on discharge prosthetic effective orifice area indexed to BSA as severe (<0.65 cm 2 /m 2) or moderate (0.65 to 0.85 cm 2 /m 2) in the general population, and as severe (<0.60 cm 2 /m 2) or moderate (0.60 to 0.90 cm 2 /m 2) in the obese population (BMI ≥ 30 kg/m 2). Results: Propensity score matching resulted in 224 matched pairs. At discharge, SEV were associated with a lower incidence of PPM compared with BEV (PPM: 33.5% vs. 46.9%, p=0.004; severe PPM: 6.7% vs. 15.6%, p=0.003). The lower frequency of severe PPM in SEV was observed even in patients with larger annulus. While patients with BSA >1.83 m 2 had a significantly lower incidence of PPM with SEV compared to BEV, there was no significant difference in patients with BSA ≤1.83 m 2. We found no impact of PPM on cardiovascular mortality or NYHA functional class at 1 year. Conclusions: SEV were associated with a lower frequency of PPM compared to BEV irrespective of annulus area. The difference was mainly driven by larger patients with BSA >1.83 m 2 .
Patient prosthesis mismatch affects short- and long-term outcomes after aortic valve replacement☆
European Journal of Cardio-Thoracic Surgery, 2006
Objective: The aim of this study was to evaluate the impact of patient prosthesis mismatch (PPM) and additional risk factors on outcome after aortic valve replacement (AVR). Methods: Four thousand one hundred and thirty-one patients who were operated between May 1996 and April 2004 were evaluated. One thousand eight hundred and fifty-six patients received bileaflet mechanical AVR and 2275 stented xenograft AVR. PPM was defined as severe if manufacturers effective orifice area (EOA) divided by body surface area (BSA) was < 0.65 cm 2 /m 2 and as moderate in the range of 0.65-0.85 cm 2 /m 2 . PPM, age, gender, EOA index, emergency indication for surgery (within 24 h), EuroSCORE as well as requirement for additional procedures were tested. Univariate (Fisher's exact test) and multivariate logistic regression analysis as well as survival analysis (Kaplan-Meier) were performed. Results: Severe PPM was present in 97 (2.4%) and moderate PPM in 1103 (26.7%) patients. PPM occurs more frequently with xenograft AVR. In-hospital mortality was 5.2% for severe, 10.6% for moderate and 6.9% with no PPM ( p = 0.018, OR 1.4). Moderate PPM was independently predictive for short-and long-term mortality. Further analysis revealed patient age > 70 years (n = 1589, p = 0.002, OR 1.85), emergency indication (n = 374, p < 0.001, OR 4.4), EuroSCORE > 10 (n = 494, p < 0.001, OR 4.7) and additional cardiac procedures (n = 2049, p < 0.001, OR 2.0) as predictors for adverse outcome after AVR. Conclusion: Severe PPM is rare; moderate PPM is present in a quarter of patients. PPM has a significant impact on short-and long-term mortality after AVR. #