Patient‐prosthesis mismatch and surgical aortic valve replacement outcomes: Retrospective analysis of single‐center surgical data

Abstract

Background Patient‐prosthesis mismatch (PPM) has been identified as a risk factor for mortality and reoperation in patients undergoing surgical aortic valve replacement (SAVR). We present a retrospective analysis of risk factors for PPM and the effects of PPM on early postoperative outcomes after SAVR. Methods Chart review was conducted for patients (N = 3003) undergoing SAVR. PPM was calculated from valve reference orifice areas and patient body surface area. Logistic regression was used to analyze risk factors for PPM and develop a risk score from these results. Regression was also conducted to identify associations between projected PPM status and postoperative outcomes. Results Risk factors for PPM included female sex, higher body mass index (BMI), and use of the St. Jude Epic valve. Patients receiving St. Jude trifecta valves or mechanical valves were less likely to have predicted PPM. We developed a risk score using BMI, sex, and valve type, and retrospectively predicted PPM in our cohort. Mild PPM (odds ratio [OR] = 2.267), severe PPM (OR = 2.869), male sex (OR = 2.091), and younger age (OR = 0.940) were all predictors of SAVR reoperation, while aortic root replacement was associated with reduced reoperation rates (OR = 0.122). Severe PPM carried a risk of in‐hospital mortality (OR = 3.599), and moderate PPM carried a smaller but significant risk (OR = 1.920). Other factors increasing postoperative morbidity and mortality included older age, renal failure, and diabetes. Conclusion PPM could be retrospectively predicted in our cohort using a risk calculation from sex, BMI and valve type. We conclude that all degrees of PPM carry risk for mortality and reoperation.

Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future

“…Nevertheless, several studies have demonstrated quite the contrary. 2,3,[8][9][10] Fallon et al 8 published a large national study using the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database including 59,779 patients ≥65 years old who underwent isolated SAVR between 2004 and 2014, revealing that patients with any degree of PPM (including moderate) had higher mortality and higher rates of readmission for congestive heart failure and redo SAVR over time owing to SVD. Additionally, a large meta-analysis 2 including 70 articles with 108,182 patients who underwent SAVR found an incidence of PPM after SAVR of 53.7% and showed that perioperative mortality, 1, 5-, and 10-year mortality, were increased in patients with PPM regardless of severity.…”

“…The impact of PPM on clinical outcomes after SAVR/TAVR is not accepted universally because several studies 4–7 failed to show PPM as a risk factor for mortality and SVD. Nevertheless, several studies have demonstrated quite the contrary 2,3,8–10 …”

Risk scores predicting patient‐prosthesis mismatch after aortic valve replacement. Where do we stand?

“…In the recent scenario, annular calcification appears to have been overcome with the new sutureless bioprosthesis. In addition, some of the results reported by Dayan et al 4 seem to contradict the outcomes reported by Gupta et al 1 They report that the impact of PPM on mortality is higher in patients less than 70 years old and when coronary artery bypass grafting surgery is a concomitant surgical procedure. Mohty et al 5 evidenced that a left ventricular ejection fraction of less than 50%, increases the long-term mortality in patients with PPM.…”

“…Mohty et al 5 evidenced that a left ventricular ejection fraction of less than 50%, increases the long‐term mortality in patients with PPM. Some echocardiographic variables presented by Gupta et al 1 would have been of interest to evaluate.…”

“…In conclusion, we have only scratched the surface on the risk factors influencing the incidence of PPM. Gupta et al 1 have paved the way for future clinical trials on this important topic. Ultimately, their research provides us with a new tool to investigate high‐risk patients and whether an aortic root enlargement should be performed instead of implanting a small aortic prosthesis.…”