Abstract
Prosthesis–patient mismatch (PPM) is present when the effective area of a prosthetic valve inserted into a patient is inferior to that of a normal human valve; the hemodynamic consequence of a valve too small compared with the size of the patient's body is the generation of higher than expected transprosthetic gradients. Despite evidence of increased risk of short- and long-term mortality and of structural valve degeneration in patients with PPM after surgical aortic valve replacement, its clinical impact in patients subject to transcatheter aortic valve implantation (TAVI) is yet unclear. We aim to review and update on the definition and incidence of PPM after TAVI, and its prognostic implications in the overall population and in higher-risk subgroups, such as small aortic annuli or valve-in-valve procedures. Last, we will focus on the armamentarium available in order to reduce risk of PPM when planning a TAVI procedure.
Highlights
Transcatheter aortic valve implantation (TAVI) in patients suffering from aortic stenosis has achieved excellent clinical results in a wide range of patients since its introduction in 2002; originally performed on inoperable patients, it has been progressively implemented in patients at lower risk over the last years, so that the latest American College of Cardiology/American Heart Association guidelines recently surpassed the surgical risk-based decision making for treatment selection in patients with aortic stenosis [1,2,3,4,5,6,7,8,9,10,11,12,13]
We propose a flowchart for differential diagnosis among the above-mentioned causes (Figure 1), mainly based on TTE with additional and complementary aid of three-dimensional TTE or transesophageal echocardiography (TEE), computed tomography (CT), and cardiac magnetic resonance (CMR)
The rate of moderate and severe prosthesis–patient mismatch (PPM) reported in the Evolut Low Risk study in patients undergoing Evolut Pro, Evolut R, and CoreValve (Medtronic, Minneapolis, Minnesota) self-expandable valve (SEV) implantation was lower than reported for balloonexpandable valve (BEV); in particular, the incidence of moderate and severe PPM after TAVI and surgical aortic valve replacement (SAVR) was 10 and 1% vs. 15 and 4%, respectively (Table 1)
Summary
Transcatheter aortic valve implantation (TAVI) in patients suffering from aortic stenosis has achieved excellent clinical results in a wide range of patients since its introduction in 2002; originally performed on inoperable patients, it has been progressively implemented in patients at lower risk over the last years, so that the latest American College of Cardiology/American Heart Association guidelines recently surpassed the surgical risk-based decision making for treatment selection in patients with aortic stenosis [1,2,3,4,5,6,7,8,9,10,11,12,13]. EOAip represents the “hemodynamic fingerprint” of the prosthetic valve: it is obtained from the published normal reference values of EOA for each model and size of THV [32], is independent of hemodynamic conditions, and is not affected by inter- and intra-observer variability of echocardiographic measurements [39, 40] It can be estimated in all patients, allowing assessment of effect of FIGURE 2 | Multimodality imaging for differential diagnosis of high trans-prosthetic gradients in patients with THV. An in vitro study assessed the characteristic of hemodynamic flow through an Evolut and a Sapien 3 THV and demonstrated major turbulence with the Evolut THV, which can be due to the different THV constructs, as recently confirmed by Hatoum et al [42, 43]
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