Background-Prosthesis-patient mismatch (P-PtM) after aortic valve replacement results in disturbed valve performance associated with increased pressure gradients. However, it is unknown whether this can be related to future structural valve deterioration (SVD) of the bioprosthesis. Methods and Results-In 564 patients (mean age, 74Ϯ5 years) receiving an aortic valve bioprosthesis, clinical follow-up (median, 6.1 years; maximum, 16.4 years) was analyzed including echocardiography. SVD was diagnosed in 40 patients (7%) as substantially increased stenosis (nϭ24) or regurgitation (nϭ16) of the operated valve over time. When patients with P-PtM (effective orifice area index Ͻ0.85 cm 2 /m 2 ; nϭ285) developed SVD, it was preferentially of the stenosis type, whereas when patients without P-PtM (nϭ279) developed SVD, the majority was of the incompetence type (PϽ0.05). Multivariable analysis including patient-and valve-related variables revealed that P-PtM and label size Յ21 were independent predictors of SVD (Pϭ0.04 and Pϭ0.02, respectively). A nonparametric Turnbull estimate analysis showed that SVD is virtually nonexistent for up to 9 years in patients without P-PtM. Thereafter, SVD starts to occur and is mainly of the incompetence-type SVD (79% of cases). In patients with P-PtM, SVD starts to occur after 2 to 3 years after implantation and is mainly of the stenosis-type SVD (81% of cases). Conclusions-These data suggest that stenosis-type SVD is an early, P-PtM-related, and thus preventable phenomenon.Incompetence-type SVD is a time-dependent, nonspecific wear damage to bioprosthetic valves, which is not related to P-PtM. (Circulation. 2010;121:2123-2129.)

It is possible to implant a well-functioning sutureless stent-mounted valve in the aortic position in less than 20 minutes of aortic crossclamping. This is associated with excellent early clinical and hemodynamic outcome in high-risk patients. Moderate changes in hematologic parameters persisted but were not related to clinical events.

Antimineralization treatment of bioprosthetic heart valves is effective and reduces the incidence of SVD significantly. Because valve type and size are determined at the moment of implantation, the surgeon carries an important responsibility in protecting the patient from valve degeneration.