Impact of Prosthesis-Patient Mismatch on Survival After Mitral Valve Replacement (original) (raw)
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The Annals of Thoracic Surgery, 2010
Background. The purpose of this study was to determine the impact of prosthesis-patient mismatch on longterm survival after mitral valve replacement. Methods. From 1992 to 2008, 765 patients underwent bioprosthetic (325; 42%) or mechanical (440; 58%) mitral valve replacement, including 370 (48%) patients older than 65 years of age. Prosthesis-patient mismatch was defined as severe (prosthetic effective orifice area to body surface area ratio <0.9 cm 2 /m 2), moderate (0.9 to 1.2 cm 2 /m 2), or absent (>1.2 cm 2 /m 2). Results. Multivariate analysis identified nine risk factors for late death including advanced age, earlier operative year, chronic renal insufficiency, peripheral vascular disease, congestive heart failure, nonrheumatic origin, concomitant coronary artery bypass grafting, lower body surface area, and more severe prosthesis-patient mismatch (lower effective orifice area to body surface area ratio; p < 0.05). For bioprosthetic recipients older than 65 years of age, survival at 5 and 10 years was 30% ؎ 7% and 0% ؎ 0% with severe mismatch compared with 43% ؎ 4% and 21% ؎ 5% for absent or moderate mismatch, respectively (p ؍ 0.05). For mechanical recipients younger than 65 years of age, survival at 5 and 10 years was 77% ؎ 4% and 62% ؎ 6% with moderate or severe mismatch compared with 82% ؎ 3% and 66% ؎ 4%, respectively, without mismatch (p ؍ 0.08). Conclusions. Severe mismatch adversely affected longterm survival for older patients receiving bioprosthetic valves. With mechanical valves, there was a trend toward impaired survival when mismatch was moderate or severe in younger patients. Thus, selection of an appropriate mitral prosthesis warrants careful consideration of age and valve type.
Impact of Prosthesis-Patient Mismatch after Mitral Valve Replacement
PubMed, 2016
Background: The study aim was to determine the impact of prosthesis-patient mismatch (PPM) on early and late clinical outcomes, left atrial and ventricular remodeling, late tricuspid valve regurgitation and pulmonary hypertension (PH) in patients after mitral valve replacement (MVR). Methods: A total of 46 patients (mean age 66 ± 9.3 years) with mitral valve diseases and undergoing isolated MVR was enrolled in the study. The mitral valve effective orifice area (EOA) was determined using the continuity equation and indexed for the patient's body surface area (EOAi). PPM was defined as EOAi ≤1.2 cm2/m2. PH was defined as a systolic pulmonary artery pressure (sPAP) >40 mmHg. Both, clinical and echocardiographic follow up were performed. Results: PPM was identified in 25% of patients, but no significant differences were observed in baseline and operative characteristics when comparing patients with and without PPM. The NYHA class was improved in most cases after surgery. Indeed, significant decreases in mean transvalvular gradient (from 8.6 ± 2.8 mmHg to 5 ± 1.3 mmHg, p = 0.001), left atrial dimension (LAD) (from 31.9 ±9.8 mm to 29.5 ± 7 mm, p = 0.011), left ventricular end-systolic diameter (from 42.6 ± 18.1 mm to 35.5 ± 6.6 mm, p = 0.044) and left ventricular end-diastolic diameter (from 55.8 ± 19.2 mm to 48.7 ± 6.1 mm, p = 0.024) were observed over time when comparing preoperative and postoperative echocardiographic data. In addition, at follow up (mean 6.9 ± 1.8 years) there were significant decreases in LAD (from 31.9 ± 9.8 mm to 28 ± 11.1 mm, p = 0.001), left ventricular enddiastolic volume (from 106.9 ± 32.9 ml to 92.3 ± 21.9 ml, p = 0.024), tricuspid regurgitation (TR) (from 87% to 27%, p = 0.002) and PH (from 78.3% to 58.7%, p = 0.043) in all patients. No significant differences were observed in hemodynamic, clinical outcome and atrial natriuretic peptide levels of patients with and without PPM. Conclusions: Mitral PPM does not appear to have any negative effect on ventricular and atrial remodeling, TR and PH during the early and late postoperative periods.
Heart, 2011
Background: Prosthesis-patient mismatch (PPM) is characterised by the effects of inadequate prosthesis size relative to body surface area (BSA).The purpose of this study was to determine the impact of PPM on late clinical outcomes after mitral valve replacement (MVR) in rheumatic population. Methods: From 2000 to 2013, a total of 445 patients (mean age 54.2 ± 11.7 years) underwent isolated MVR (±tricuspid annuloplasty) for rheumatic disease were investigated. Effective orifice area (EOA) was determined by the continuity equation and PPM was defined as indexed EOA (EOA/BSA) ≤ 1.2 cm 2 /m 2 . Clinical and echocardiographic follow-up (mean follow up 8.7 ± 4.0 years) results were compared. Results: 37% of patients (n = 165) had PPM. There were no significant differences in baseline and operative characteristics between patients with and without PPM except age and IEOA. A significant decrease in mean trans-valvular pressure gradient (MPG) over time following MVR, however the change of MPG showed no differences between groups (No PPM vs. PPM: 8.9 ± 4.7 mmHg → 3.6 ± 1.2 mmHg vs. 8.7 ± 4.5 mmHg → 3.8 ± 1.4 mmHg, p-value = 0.28). In all patients, there was a reduction of left atrium dimension (58.6 ± 12.0 mm → 53.2 ± 12.0 mm vs. 57.9 ± 8.9 mm → 52.2 ± 8.9 mm, p-value = 0.68) and left ventricular end diastolic diameter (49.9 ± 5.7 mm → 48.9 ± 5.7 mm vs. 49.7 ± 6.0 mm → 48.3 ± 5.0 mm, p = 0.24) without statistical significance. Freedom from TR progression rates at 3 and 5 years (99% vs.98%, 99% vs. 98%, p-value = 0.1), and overall survival rates at 3 and 5 years (97% vs. 96%, 94% vs. 94%, p-value = 0.7) were similar. This study shows that mitral PPM is not associated with atrial /ventricular remodeling and might not influence late clinical outcome including late TR progression, survival in rheumatic population.
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. #
Brazilian Journal of Cardiovascular Surgery, 2019
Objective: This study sought to evaluate the impact of prosthesis-patient mismatch on the risk of perioperative and longterm mortality after mitral valve replacement. Methods: Databases were researched for studies published until December 2018. Main outcomes of interest were perioperative and 10-year mortality and echocardiographic parameters. Results: The research yielded 2,985 studies for inclusion. Of these, 16 articles were analyzed, and their data extracted. The total number of patients included was 10,239, who underwent mitral valve replacement. The incidence of prosthesis-patient mismatch after mitral valve replacement was 53.7% (5,499 with prosthesispatient mismatch and 4,740 without prosthesis-patient mismatch). Perioperative (OR 1.519; 95%CI 1.194-1.931, P<0.001) and 10-year (OR 1.515; 95%CI 1.280-1.795, P<0.001) mortality was increased in patients with prosthesis-patient mismatch. Patients with prosthesis-patient mismatch after mitral valve replacement had higher systolic pulmonary artery pressure and transprosthethic gradient and lower indexed effective orifice area and left ventricle ejection fraction. Conclusion: Prosthesis-patient mismatch increases perioperative and long-term mortality. Prosthesis-patient mismatch is also associated with pulmonary hypertension and depressed left ventricle systolic function. The findings of this study support the implementation of surgical strategies to prevent prosthesispatient mismatch in order to decrease mortality rates.
Patient-prosthesis mismatch in the mitral position affects midterm survival and functional status
Canadian Journal of Cardiology, 2010
P atient-prosthesis mismatch (PPM) in the aortic position has been studied for a decade and is a widely accepted concept, although its exact influence on long-term outcome remains controversial (1). Despite the fact that the cardiac output is the same through the aortic and the mitral valve, the adequacy between a patient's surface area and the valve's area has been less studied in the mitral position. The consequence of Poiseuille's law related to the given cardiac output that flows through a restrictive mitral valve is more obscure in the mitral position. Thus, the clinical impacts might be more difficult to identify and the threshold ratio between the effective orifice area (EOA) of the valve and the body surface area (BSA) defined as the indexed EOA (EOAi) remains to be defined. A strong correlation was identified between the persistence of residual pulmonary hypertension after mitral valve replacement and an EOAi of lower than 1.2 cm 2 /m 2 (2). The same threshold was associated with recurrent heart failure and worse longterm survival (3,4). Some studies on this subject have included bioprosthetic valves that are subject to deterioration, especially in the mitral position, with a theoretical orifice area that could be overestimated compared with the actual one, especially a few years after implantation. The main objective of the present study was to evaluate the incidence of mitral PPM in a large population of patients with mechanical mitral valve replacement and its effect on long-term outcome. clinical studies ©2010 Pulsus Group Inc. All rights reserved D Bouchard, F Vanden Eynden, P Demers, et al. Patient-prosthesis mismatch in the mitral position affects midterm survival and functional status. Can J Cardiol 2010;26(10):532-536. BACKGROUND: The definition and incidence of patient-prosthesis mismatch (PPM) in the mitral position are unclear. OBJECTIVES: To determine the impact of PPM on late survival and functional status after mitral valve replacement with a mechanical valve. METHODS: Between 1992 and 2005, 714 patients (mean [± SD] age 60±10 years) underwent valve replacement with either St Jude (St Jude Medical Inc, USA) (n=295) or Carbomedics (Sulzer Carbomedics Inc, USA) (n=419) valves. There were 52 concomitant procedures (50 tricuspid annuloplasties, 25 foramen oval closures and 20 radiofrequency mazes).
International Journal of Cardiology, 2013
Background: Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR). Aim of the present study is to evaluate the impact of mitral prosthesis-patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH). Methods: A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi ≤ 1.2 cm 2 /m 2 . Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP) N 40 mmHg. Clinical and echocardiographic follow-up (median 27 months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM. Results: There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR ≥ 2+ (57%vs.22%; p = 0.0001), and PH (62%vs.24%; p b 0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p b 0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p b 0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p b 0.0001) and LV ejection fraction (p b 0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM. Conclusions: This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.
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.