Abstract
ObjectiveThe hemodynamic effect and early and late survival impact of prosthesis–patient mismatch (PPM) after mitral valve replacement remains insufficiently explored.MethodsPubmed, Embase, Web of Science, and Cochrane Library databases were searched for English language original publications. The search yielded 791 potentially relevant studies. The final review and analysis included 19 studies compromising 11,675 patients.ResultsProsthetic effective orifice area was calculated with the continuity equation method in 7 (37%), pressure half‐time method in 2 (10%), and partially or fully obtained from referenced values in 10 (53%) studies. Risk factors for PPM included gender (male), diabetes mellitus, chronic renal disease, and the use of bioprostheses. When pooling unadjusted data, PPM was associated with higher perioperative (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.32–2.10; p < .001) and late mortality (hazard ratio [HR]: 1.46; 95% CI: 1.21–1.77; p < .001). Moreover, PPM was associated with higher late mortality when Cox proportional‐hazards regression (HR: 1.97; 95% CI: 1.57–2.47; p < .001) and propensity score (HR: 1.99; 95% CI: 1.34–2.95; p < .001) adjusted data were pooled. Contrarily, moderate (HR: 1.01; 95% CI: 0.84–1.22; p = .88) or severe (HR: 1.19; 95% CI: 0.89–1.58; p = .24) PPM were not related to higher late mortality when adjusted data were pooled individually. PPM was associated with higher systolic pulmonary pressures (mean difference: 7.88 mmHg; 95% CI: 4.72–11.05; p < .001) and less pulmonary hypertension regression (OR: 5.78; 95% CI: 3.33–10.05; p < .001) late after surgery.ConclusionsMitral valve PPM is associated with higher postoperative pulmonary artery pressure and might impair perioperative and overall survival. The relation should be further assessed in properly designed studies.
Highlights
Prosthesis–patient mismatch (PPM) has been intensively studied in patients after aortic valve replacement.[1,2] In contrast, the hemodynamic and clinical consequences of PPM following mitral valve replacement (MVR) are less well established.PPM after valve replacement occurs due to a mismatch in the prosthetic valve effective orifice area (EOA) in relation to the patient's body size, which is being used as an approximation of the patient's cardiac output
Observed as the incidence of PPM ranged from 7% when measured with the pressure half‐time (PHT) method to 49% and 62% when obtained from referenced values or measured with the continuity equation (CE) method, respectively
Dumesnil et al.[27] reported that the PHT method overestimates the EOA when compared with the CE method and the use of the PHT has been discouraged in a recent recommendation by the European Association of Cardiovascular Imaging.[28]
Summary
Prosthesis–patient mismatch (PPM) has been intensively studied in patients after aortic valve replacement.[1,2] In contrast, the hemodynamic and clinical consequences of PPM following mitral valve replacement (MVR) are less well established. MVR remains a common procedure and contemporary data from the Society of Thoracic Surgery database demonstrate that MVR is performed in more than 40% of patients undergoing MV surgery in North America.[3] The clinical consequences of PPM after MVR remain unclear as contradicting results, with some studies showing impaired outcomes in the presence of PPM4,5 while others have failed to do so,[6,7] have been published to date. Either possibly related to the development of PPM or presenting a possible consequence of PPM, the following data were extracted: study design, number of patients, baseline characteristics, method of EOA determination, indexed EOA cut‐off threshold for PPM, and the number of patients with PPM.
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