Impact of patient-prosthesis mismatch on 30-day outcomes in young and middle-aged patients undergoing aortic valve replacement

Hernández-Vaquero, Daniel; Llosa, Juan C.; Díaz, Rocío; Khalpey, Zain; Morales, Carlos; Álvarez, Rubén; Lopez, J.; Boye, Francisco J.

doi:10.1186/1749-8090-7-46

Cited by 20 publications

(14 citation statements)

References 20 publications

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“…One study18 also reported a longer ventilation time and intensive care unit stay in patients with PPM. Inotrope requirement was noted to be higher in those with PPM in one study,21 while a different study reported higher use of an intra-aortic balloon pump postoperatively 20. Patients with AS undergoing AVR tend to be older and have multiple comorbidities, and those likely to have PPM often have a smaller body size.…”

Section: Clinical Outcomesmentioning

confidence: 98%

Patient-prosthesis mismatch following aortic valve replacement

Bilkhu

Jahangiri

Otto

2019

Heart

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Patient-prosthesis mismatch (PPM) occurs when an implanted prosthetic valve is too small for the patient; severe PPM is defined as an indexed effective orifice area (iEOA) <0.65 cm2/m2 following aortic valve replacement (AVR). This review examines articles from the past 10 years addressing the prevalence, outcomes and options for prevention and treatment of PPM after AVR. Prevalence of PPM ranges from 8% to almost 80% in individual studies. PPM is thought to have an impact on mortality, mainly in patients with severe PPM, although severe PPM accounts for only 10–15% of cases. Outcomes of patients with moderate PPM are not significantly different to those without PPM. PPM is associated with higher rates of perioperative stroke and renal failure and lack of left ventricular mass regression. Predictors include female sex, older age, hypertension, diabetes, renal failure and higher surgical risk score. PPM may be a marker of comorbidity rather than a risk factor for adverse outcomes. PPM should be suspected in patients with persistent cardiac symptoms after AVR when there is high prosthetic valve velocity or gradient and a small calculated effective orifice area. After exclusion of other causes of increased transvalvular gradient, re-intervention may be considered if symptoms persist and are unresponsive to medical therapy. However, this decision needs to consider the available options to relieve PPM and whether expected benefits justify the risk of intervention. The only effective intervention is redo surgery with implantation of a larger valve and/or annular enlargement. Therefore, focus needs to be on prevention.

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Section: Clinical Outcomesmentioning

confidence: 98%

Patient-prosthesis mismatch following aortic valve replacement

Bilkhu

Jahangiri

Otto

2019

Heart

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“…PPM is defined as none by an EOA index >0.85 cm 2 /m 2 , as moderate at 0.65–0.85 cm 2 /m 2 and as severe at <0.65 cm 2 /m 2 . Moderate and severe PPM increases operative mortality by 2.1- and 11.4-fold, respectively [ 25 ]. Several studies indicate that moderate PPM is found in up to 30% of patients after AVR and, in some cases, complex reoperations are required in order to prevent congestive heart failure.…”

Section: Discussionmentioning

confidence: 99%

Decellularized aortic homografts for aortic valve and aorta ascendens replacement

Tudorache

Horke

Cebotari

et al. 2016

Eur J Cardiothorac Surg

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OBJECTIVESThe choice of valve prosthesis for aortic valve replacement (AVR) in young patients is challenging. Decellularized pulmonary homografts (DPHs) have shown excellent results in pulmonary position. Here, we report our early clinical results using decellularized aortic valve homografts (DAHs) for AVR in children and mainly young adults.METHODSThis prospective observational study included all 69 patients (44 males) operated from February 2008 to September 2015, with a mean age of 19.7 ± 14.6 years (range 0.2–65.3 years). In 18 patients, a long DAH was used for simultaneous replacement of a dilated ascending aorta as an extended aortic root replacement (EARR). Four patients received simultaneous pulmonary valve replacement with DPH.RESULTSThirty-nine patients (57%) had a total of 62 previous operations. The mean aortic cross-clamp time in isolated cases was 129 ± 41 min. There was 1 conduit-unrelated death. The mean DAH diameter was 22.4 ± 3.7 mm (range, 10–29 mm), the average peak gradient was 14 ± 15 mmHg and the mean aortic regurgitation grade (0.5 = trace, 1 = mild) was 0.6 ± 0.5. The mean effective orifice area (EOA) of 25 mm diameter DAH was 3.07 ± 0.7 cm2. DAH annulus z-values were 1.1 ± 1.1 at implantation and 0.7 ± 1.3 at the last follow-up. The last mean left ventricle ejection fraction and left ventricle end diastolic volume index was 63 ± 7% and 78 ± 16 ml/m2 body surface area, respectively. To date, no dilatation has been observed at any level of the graft during follow-up; however, the observational time is short (140.4 years in total, mean 2.0 ± 1.8 years, maximum 7.6 years). One small DAH (10 mm at implantation) had to be explanted due to subvalvular stenosis and developing regurgitation after 4.5 years and was replaced with a 17 mm DAH without complication. No calcification of the explanted graft was noticed intraoperatively and after histological analysis, which revealed extensive recellularization without inflammation.CONCLUSIONSDAHs withstand systemic circulation, provide outstanding EOA and appear as an alternative to conventional grafts for AVR in young patients. EARR using DAH is a further option in aortic valve disease associated with aorta ascendens dilatation as it avoids the use of any prosthetic material.

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“…Supporting these findings is the group of Toronto who refer 8% mortality rate for patients with PPM and 5% in the group without MPP (p = 0.003). The last two groups referred to the moderate PPM and recommend the need to prevent the occurrence of PPM [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

Incidence and Impact of Patient-Prosthesis Mismatch in Isolated Aortic Valve Surgery

Dumani

Likaj

Kacani

et al. 2014

Open Access Maced J Med Sci

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AIM:The mains topics of this work are the incidence of patient-prosthesis mismatch and the influence in the early results of isolated aortic valve surgery.METHODS:In 193 patients isolated aortic valve surgery was performed. The study population was divided in three subgroups: 20 patients with severe, 131 patients with moderate and 42 patients without patient-prosthesis mismatch. The indexed effective orifice area was used to define the subgroups. Operative mortality and perioperative complications were considered the indicators of the early results of aortic valve surgery.RESULTS:The incidence of severe and moderate patient-prosthesis mismatch was respectively 10.3% and 67.8%. Hospital mortality and perioperative complications were: mortality 5% vs. 3.1% vs. 2.4% (p = 0.855), low cardiac output 5% vs. 6.9% vs. 4.8% (p = 0.861); pulmonary complications 5% vs. 3.1 vs. 0.0% (p = 0.430); exploration for bleeding 5% vs. 0.8% vs. 2.4% (p = 0.319); atrial fibrillation 30% vs. 19.8% vs. 11.9% (p = 0.225); wound infection 5% vs. 0.8% vs. 0.00% (p = 0.165), respectively for the group with severe, moderate and without patient-prosthesis mismatch.CONCLUSIONS:Patient-prosthesis mismatch is a common occurrence in aortic valve surgery. This phenomenon does not affect the early results of aortic valve surgery.

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Impact of patient-prosthesis mismatch on 30-day outcomes in young and middle-aged patients undergoing aortic valve replacement

Cited by 20 publications

References 20 publications

Patient-prosthesis mismatch following aortic valve replacement

Patient-prosthesis mismatch following aortic valve replacement

Decellularized aortic homografts for aortic valve and aorta ascendens replacement

Incidence and Impact of Patient-Prosthesis Mismatch in Isolated Aortic Valve Surgery

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