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Background: To predict the occurrence of valve prosthesis-patient mismatch (VP-PM) after aortic valve replacement (AVR), the surgeon needs to estimate the postoperative effective orifice area index (EOAI). Aim: To compare different methods of predicting VP-PM. Methods: The effective orifice area (EOA) of 383 patients who had undergone AVR between July 2000 and January 2005 with various aortic valve prostheses was obtained echocardiographically 6 months after the operation. We tested the efficacy of (1) EOAI calculated from the echo data obtained in our own laboratory, (2) indexed geometric orifice area, (3) EOAI estimated from charts provided by prosthesis manufacturers (which are based either on in vitro or on echo data) and (4) EOAI estimated from reference echo data published in the literature to predict VP-PM. Results: Sensitivity and specificity to predict VP-PM were 53% and 83% (method 1), 80% and 53% (charts based on echo data, parts of method 3) and 71% and 67% (method 4) using reference data derived from echocardiographic examinations. The sensitivity of method 2 and of charts based on in vitro data (parts of method 3) to predict VP-PM was 0-17%. The incidence of severe VP-PM could be reduced from 8.7% to 0.8% after the introduction of the systematic estimation of the EOAI at the time of operation (p = 0.003, method 1). Conclusions: The best method of predicting VP-PM is the use of mean (SD) EOAs derived from echocardiographic examinations, whereas the use of in vitro data or the geometric orifice area is unreliable. After the surgeon's anticipation of VP-PM prior to AVR, the incidence of VP-PM could be reduced.

Background There has been ongoing controversy as to whether prosthesisepatient mismatch (PPM, defined as indexed effective orifice area (EOAI) <0.85 m 2 /cm 2 ) influences mortality after aortic valve replacement (AVR). In most studies, PPM is anticipated by reference tables based on mean EOAs as opposed to individual assessment. These reference values may not reflect the actual in vivo EOAI and hence, the presence or absence of PPM may be based on false assumptions. Objective To assess the impact of small prosthesis EOA on survival after aortic valve replacement AVR. Methods 645 patients had undergone an AVR between 2000 and 2007 entered the study. All patients underwent transthoracic echocardiography for determination of the actual EOAI within 6 months postoperatively. In order to predict time from surgery to death a proportional hazards model for competing risks (cardiac death vs death from other causes) was used. EOAI was entered as a continuous variable. Results PPM occurred in 40% of the patients. After a median follow-up of 2.35 years, 92.1% of the patients were alive. The final Cox regression model showed a significantly increased risk for cardiac death among patients with a smaller EOAI (HR¼0.32, p¼0.022). The effect of EOAI on the 2e5 year mortality risk was demonstrated by risk plots. Conclusions In contrast to previous studies these EOAI values were obtained through postoperative echocardiography, substantially improving the accuracy of measurement, and the EOAI was modelled as a continuous variable. There was a significantly improved survival for larger EOAIs following AVR. Strategies to avoid PPM should become paramount during AVR.

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Repair, as opposed to replacement, is feasible in the vast majority of patients presenting with Ebstein's anomaly with a low early mortality rate. Outcome, in terms of survival and freedom from re-operation in the long term is determined by the clinical state at the time of surgery. Therefore, timely operation is warranted before significant cardiomegaly develops and functional status deteriorates.

The present study reveals a significant impact of PPM on physical capacity, measured by exercise testing, in patients after AVR. Although other factors such as training status and comorbidity (for example, concomitant coronary revascularisation) also influence the achievement of higher exercise levels, our data strengthen the hypothesis that the avoidance of PPM could result in better exercise capacity for patients after AVR.

Background— Complete supraannular placement of an aortic bioprosthesis is one approach to optimize the hemodynamic result of an aortic valve replacement. It is achieved with the combination of a special valve design and the supraannular sewing technique with noneverted mattress sutures. We evaluated 5 bioprostheses designed for complete supraannular placement to assess potential hemodynamic differences caused by factors (eg, valve material) other than implantation position. Methods and Results— In 336 patients (mean age, 72.0±7.1 years; 143 women), hemodynamics including mean pressure gradients, effective orifice areas, and indices and incidence of patient-prosthesis mismatch were evaluated 6 months after surgery. Annulus diameter was measured during surgery. Patients received the Carpentier Edwards Perimount Magna (Magna, n=169), the Medtronic Mosaic (Mosaic, n=46), the Mosaic Ultra (Ultra, n=17), the SJM Epic Supra (Epic, n=46), and the Sorin Soprano (Soprano, n=58). For small annulus sizes (<23 mm), the mean pressure gradients of the Magna (11.82±4.8 mm Hg) were significantly lower than the Mosaic (16.04±6.1 mm Hg) and the Ultra (22.0±4.1 mm Hg), and the Soprano (13.3±5.2 mm Hg) was hemodynamically superior to the Ultra. For medium (23 to 24 mm) and large (>24 mm) annulus sizes, the mean pressure gradients of the Magna were lower than the Epic (10.0±3.5 mm Hg versus 14.9±6.4 mm Hg; 9.9±4.0 mm Hg versus 18.6±12.7 mm Hg). Furthermore, in patients with large annulus size, the mean pressure gradients of the Soprano (11.4±3.8 mm Hg) were lower compared with the Epic (18.5±12.7 mm Hg). Severe patient-prosthesis mismatch was observed more frequently in patients with the Mosaic (12/46; 26.1%) and the Ultra (3/17; 17.6%) prostheses. Conclusions— Complete supraannular placement cannot prevent high pressure gradients or patient-prosthesis mismatch thoroughly, but the choice of a bovine prosthesis can optimize hemodynamic performance.

ObjectivesTo investigate the prevalence of chronic comorbidities and the use of comedications in people living with HIV (PLWH) and on antiretrovirals in Japan, by using a hospital claims database.DesignObservational, retrospective, cross-sectional study.SettingA hospital claims database of Japanese hospitals that have advanced medical treatment capabilities (ie, advanced treatment hospitals, general hospitals, acute care hospitals), which include those providing acute and chronic care (excluding nursing homes or hospices).ParticipantsA total of 1445 PLWH aged ≥18 years and with a prescription record of antiretrovirals between January 2010 and December 2015 were identified from the database.Outcome measuresThe number and types of chronic comorbidities, as well as the number and types of comedications, in different age groups of the PLWH.ResultsThe median (range) age of patients was 45 (18–90) years, and 90.4% were men. Of the 1445 patients, 972 (67.3%) had at least one chronic comorbidity. Common chronic comorbidities included lipid disorders (31.6%), diabetes (26.8%), hypertension (18.2%) and hepatitis B/C coinfection (18.2%). Patients in the older age groups had greater numbers of chronic comorbidities. The most common chronic comorbidities in the older age groups were hypertension, diabetes and lipid disorders. The majority of patients used at least one comedication, and those in the older age groups used greater numbers of comedications. The most common therapeutic category of comedication included antacids, antiflatulents and antiulcerants (31.7%). Of 151 malignancies reported in 117 patients, 84 were AIDS-defining cancers and 67 were non-AIDS-defining cancers.ConclusionsChronic comorbidities and comedications were common among PLWH in Japan taking antiretrovirals; particularly among older patients, who more frequently used comedications. This suggests the need for giving special attention to the appropriate management of this patient population.