Patient prosthesis mismatch is rare after aortic valve replacement: valve size may be irrelevant.
ABSTRACT Although small valve size and patient-prosthesis mismatch are both considered to decrease long-term survival, little direct evidence exists to support this hypothesis.
To assess the prevalence of patient-prosthesis mismatch and the influence of small valve size on survival, we prospectively studied 1,129 consecutive patients undergoing aortic valve replacement between 1990 and 2000. Mean and peak gradients and indexed effective orifice area were measured by transthoracic echocardiography postoperatively (3 months to 10 years). Abnormal postoperative gradients were defined as those patients with mean or peak gradient above the 90th percentile (mean gradient > or = 21 or peak gradient > or = 38 mm Hg). Patient-prosthesis mismatch was defined as those patients with indexed effective orifice area below the 10th percentile (< 0.60 cm2/m2).
A multivariable analysis identified internal diameter of the implanted valve as the only independent predictor of abnormal gradients postoperatively. However, there was no significant difference in actuarial survival between normal and abnormal gradient groups (7 years: 91.2% +/- 1.5% versus 95.0% +/- 2.2%; p = 0.48). Freedom from New York Heart Association class III or IV (7 years: 74.5% +/- 3.1% versus 74.6% +/- 6.2%; p = 0.66) and left ventricular mass index were not different between normal and abnormal gradient groups. Patients with and without patient-prosthesis mismatch were similar with respect to postoperative left ventricular mass index, 7-year survival (95.1% +/- 1.3% versus 94.7% +/- 3.0%; p = 0.54), and 7-year freedom from New York Heart Association class III or IV (79.3% +/- 6.6% versus 74.5% +/- 2.5%; p = 0.40). In patients with patient-prosthesis mismatch and abnormal gradients, the majority had prosthesis dysfunction owing to degeneration.
Severe patient-prosthesis mismatch is rare after aortic valve replacement. Patient-prosthesis mismatch, abnormal gradient, and the size of valve implanted do not influence left ventricular mass index or intermediate-term survival.
- Journal of cardiothoracic and vascular anesthesia 10/2013; · 1.06 Impact Factor
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ABSTRACT: The clinical effects of prosthesis-patient mismatch (PPM) after aortic valve replacement, with respect to morbidity and survival, remain controversial, particularly in high-risk patient subgroups. Patients undergoing aortic valve replacement from January 1992 to December 2010 were classified according to effective orifice area index into severe PPM (effective orifice area index < 0.65 cm²/m²), moderate PPM (effective orifice area index 0.65 to 0.85 cm²/m²), and absent PPM (effective orifice area index > 0.85 cm²/m²). Analyses examined major morbidity and total all-cause death. Prosthesis-patient mismatch was classified as severe (92 of 1,060; 8.7%), moderate (440 of 1,060; 41.5%), or absent (528 of 1,060; 49.8%). Moderate and severe PPM were unrelated to in-hospital morbidity or mortality. There were 440 deaths (41.5%) at 5.6 years median follow-up (interquartile range, 2.9 to 9.1). Trend toward poorer survival according to PPM group (χ(2) = 5.46; p = 0.07) was attenuated further with covariate adjustment. Sensitivity analyses demonstrated discrete mortality effects for moderate PPM in association with concomitant coronary artery bypass grafting, impaired left ventricular function, and older age (significant hazard ratios range, 1.05 to 1.57). Severe PPM also increased mortality risk in association with older age, concomitant coronary artery bypass grafting, and New York Heart Association Class III or IV (significant hazard ratios range, 1.06 to 2.65). Prosthesis-patient mismatch was not associated with mortality in covariate-adjusted models. However, a discrete mortality risk was attributable to moderate and severe PPM in patients of older age, or those with left ventricular dysfunction, New York Heart Association class III or IV, and concomitant coronary artery bypass grafting.The Annals of thoracic surgery 06/2013; · 3.45 Impact Factor
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ABSTRACT: BACKGROUND AND AIM OF THE STUDY: To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. METHODS: Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm(2) /m(2) . Patients having IEOA < 0.75 cm(2) /m(2) and IEOA < 0.60 cm(2) /m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. RESULTS: PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2) , and 23 had an IEOA ≤ 0.60 cm(2) /m(2) . The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. CONCLUSIONS: PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.Journal of Cardiac Surgery 05/2013; · 1.35 Impact Factor