Prevalence and Long-Term Outcome of Aortic Prosthesis–Patient Mismatch in Patients With Paradoxical Low-Flow Severe Aortic Stenosis

Abstract

Background— Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) have worse outcome compared with those with normal flow. Furthermore, prosthesis–patient mismatch (PPM) after aortic valve replacement is a predictor of reduced survival. However, the prevalence and prognostic impact of PPM in patients with PLF-AS are unknown. We aimed to analyze the prevalence and long-term survival of PPM in patients with PLF-AS. Methods and Results— Between 2000 and 2010, 677 patients with severe AS, preserved left ventricular ejection fraction, and aortic valve replacement were included (74±8 years; 42% women; aortic valve area, 0.69±0.16 cm 2 ). A PLF (indexed stroke volume ≤35 mL/m 2 ) was found in 26%, and after aortic valve replacement, 54% of patients had PPM, defined as an indexed effective orifice area ≤0.85 cm 2 /m 2 . The combined presence of PLF and PPM was found in 15%. Compared with patients with noPLF/noPPM, those with PLF/PPM were significantly older, with more comorbidities. They also received smaller and biological bioprosthesis more often (all P <0.01). Although early mortality was not significantly different between groups, the 10-year survival rate was significantly reduced in case of PLF/PPM compared with noPLF/noPPM (38±9% versus 70±5%; P =0.002), even after multivariable adjustment (hazard ratio, 2.58; 95% confidence interval, 1.5–4.45; P =0.0007). Conclusions— In this large catheterization-based study, the coexistence of PLF-AS before surgery and PPM after surgery is associated with the poorest outcome.

Paradoxical low-flow, low-gradient severe aortic stenosis: a distinct disease entity

“…Despite the lack of superiority as compared to surgery, TAVI may represent a valuable alternative for patients with paradoxical LFLG AS, given that they are at a more advanced stage of ventricular disease and that they are at a higher risk for severe prosthesis–patient mismatch and associated complications following surgical AVR 7 8…”

Low Flow Low Gradient Severe Aortic Stenosis: Diagnosis and Treatment

“…Certain factors intrinsic to patients with paradoxical LFLG AS pose higher surgical risks compared to patients with high gradient AS. These include higher prevalence in female sex, older age, systemic hypertension, atrial fibrillation, restrictive LV physiology and smaller aortic annulus that predisposes to patient prosthesis mismatch [52][53][54]. TAVR was associated with better 1-year survival compared with SAVR in patients with paradoxical LFLG AS in the PARTNER-I Cohort A trial.…”

Prosthesis-patient mismatch - what cardiac anesthesiologists need to know?

“…[10] The most susceptible patients include the ones with coronary artery disease requiring revascularization, depressed LV systolic function, severe LV hypertrophy, significant diastolic dysfunction, concomitant MR, and paradoxical low-flow low-gradient aortic stenosis (PLF-LG AS). [29303132] It is also known that patients with a bioprosthesis have a three-time higher risk of developing PPM compared to those with mechanical AVs. [10]…”

“…Ten-year survival was significantly affected in patients with PLF-AS and PPM compared with patients with no PPM or no PLF-AS. [32]…”