Clinical predictors of prosthesis-patient mismatch after aortic valve replacement for aortic stenosis

Abstract

OBJECTIVE:We sought to ascertain predictors of Patient Prosthesis Mismatch, an independent predictor of mortality, in patients with aortic stenosis using bioprosthetic valves.METHOD:We analyzed 2,107 sequential surgeries. Patient Prosthesis Mismatch was calculated using the effective orifice area of the prosthesis divided by the patient's body surface area. We defined nonsignificant, moderate, and severe Patient Prosthesis Mismatch as effective orifice area indexes of >0.85 cm2/m, 0.85-0.66 cm2/m2, and ≤0.65 cm2/m2, respectively.RESULTS:A total of 311 bioprosthetic patients were identified. The incidence of nonsignificant, moderate, and severe Patient Prosthesis Mismatch was 41%, 42, and 16%, respectively. Severe Patient Prosthesis Mismatch was significantly more prevalent in females (82%). In severe Patient Prosthesis Mismatch, the perfusion and the cross-clamp times were considerably lower when compared with nonsignificant Patient Prosthesis Mismatch and moderate Patient Prosthesis Mismatch. Patients with severe Patient Prosthesis Mismatch had a significantly higher likelihood of spending time in the intensive care unit and a significantly longer length of stay in the hospital. Body surface area was not different in severe Patient Prosthesis Mismatch when compared with nonsignificant Patient Prosthesis Mismatch. In-hospital mortality in patients with nonsignificant, moderate, and severe Patient Prosthesis Mismatch was 2.3%, 6.1%, and 8%, respectively. Minimally invasive surgery was significantly associated with moderate Patient Prosthesis Mismatch in 49% of the patients, but not with severe Patient Prosthesis Mismatch.CONCLUSION:Severe Patient Prosthesis Mismatch is more common in females, but not in those with minimal available body surface area. Though operative times were shorter in these patients, intensive care unit and hospital lengths of stay were longer. Surgeons and cardiologists should be cognizant of these clinical predictors and complications prior to valve surgery.

On the Mechanics of Transcatheter Aortic Valve Replacement

“…Successively Dumesnil and Pibarot explained that this definition can be applied to almost all valve replacements 28 . Therefore, the heart must overcome the additional flow resistance via elevated pressures 10 . Gorlin and Hakki 46 describe that transvalvular gradients depend on both EOA and transvalvular flow rate.…”

Transcatheter Replacement of Failed Bioprosthetic Valves

“…A meta-analysis including >27 000 patients undergoing surgical aortic valve replacement and other studies have shown that both moderate and severe PPM are associated with worse outcomes. [20][21][22] Another concern with elevated gradients is a reduction in valve durability and increased valve degeneration. 23 Before this study, there was no clear method for preventing this common adverse event of ViV procedures.…”

Cardiac surgery Early clinical outcomes of the surgical treatment of patients with aortic stenosis and small aortic annuli

“…According to some reports, the occurrence of PPM, in particular severe PPM, appears to be a factor which increases mortality during the early postoperative period [12]. In our study, almost all perioperative deaths occurred in patients with small aortic annuli, among whom 87% suffered from severe PPM.…”

“…Selecting prosthetic valves of appropriate sizes is particularly important in the case of patients with small aortic annuli, whose EOA is relatively small [12].…”