Prosthesis-Patient Mismatch Predicts Structural Valve Degeneration in Bioprosthetic Heart Valves

Abstract

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.)

Reducing Prosthesis-Patient Mismatch With Edwards Magna Prosthesis for Aortic Valve Replacement

“…6 It has been suggested that PPM has a significant effect on short-term and long-term outcomes. [7][8][9] Because the NOTION trial showed that the incidence of PPM was lower after TAVR than after surgical AVR at the mid-term follow-up, the hemodynamic performance of TAVR is not inferior compared with surgical AVR. 10 Therefore, avoiding PPM by choosing an appropriate bioprosthesis is crucial for surgical AVR.…”

Patient-Prosthesis Mismatch After Aortic Valve Replacement

“…There is now a strong body of evidence that PPM has an impact on functional class, regression of left ventricular hypertrophy, left ventricular function, coronary flow reserve, rate of valve degeneration and more importantly, mortality (Tasca et al, 2005, Flameng et al, 2010. Over time it has become clear that the impact of PPM depends greatly on the clinical condition of the patients.…”

“…These patients will have less "EOA reserve" if PPM is present. Higher gradient and stenosis will tend to develop faster with the combination of degeneration and PPM (Flameng et al, 2010).…”

“…PPM is also associated with a number of other adverse outcomes with variable clinical importance: reduced quality of life, reduced exercise capacity (Bleiziffer et al, 2008), more important residual mitral regurgitation (Unger et al, 2010), the risk of early degeneration of bioprosthetic valve with stenotic lesions (Flameng et al, 2010) and increased risk of hemorrhagic complication due to the acquired abnormalities of the Von Willebrand factor (Vincentelli et al, 2003).…”

Long-Term Survival Following Aortic Valve Replacement: the Influence of Age, Prosthesis-Patient Mismatch and Indexed Effective Orifice Area

“…[10] Late cardiac complications [11] and accelerated degeneration of bioprostheses have also been reported. [12] However, in the setting of advancing age, the combined effects of these factors on survival remains unclear. [13,14] Although age undoubtedly increases early and late mortality after aortic valve replacement, the direct effect of mismatch remains debatable.…”