Moderate Prosthesis-patient Mismatch Research Articles

Sex Disparities in Hemodynamics and Outcomes in Patients Who Underwent Contemporary Transcatheter Aortic Valve Implantation

Studies have reported worse outcomes after transcatheter aortic valve implantation (TAVI) in women receiving early generation transcatheter heart valves (THVs). They have smaller aortic annuli, which could result in higher gradients and more patient-prosthesis mismatch (PPM) after TAVI. We investigated the interactions between contemporary THV hemodynamics and outcomes in women who underwent TAVI. We conducted a retrospective, observational study of patients who underwent contemporary TAVI from 2015 to 2020. We compared baseline characteristics, in-hospital outcomes, and hemodynamics according to sex. We then dichotomized women according to aortic annular area (<430 or ≥430 mm2). Included were 869 patients who underwent TAVI with the SAPIEN 3 or CoreValve Evolut PRO/PRO+. Most patients with small annuli were female (82.5%). They had nonsignificantly higher mortality (30-day: 1.5% vs 0.6%, p=0.313; 1-year: 4.1% vs 2.7%, p=0.265). Those who received self-expanding THVs had lower gradients (8.0 mm Hg vs 13.8 mm Hg, p <0.001), resulting in less moderate PPM (21.2% vs 73.6%, p <0.001), similar severe PPM (19.5% vs 15.3%, p=0.454), and higher rates of pacemaker implantation (14.4% vs 4.2%, p=0.009). Women with small annuli who received a balloon-expandable THV had nonsignificantly higher mortality (30-day: 2.1% vs 0.8%, p=0.631; 1-year: 6.3% vs 1.7%, p=0.118). In conclusion, women who underwent contemporary TAVI had nonsignificantly higher mortality, which could be due to higher PPM rates. These findings were more pronounced in the subset of women with small annuli, in whom those who received self-expanding THVs demonstrated superior hemodynamics at the cost of increased rates of pacemaker implantation.

Incidence of Prosthesis-Patient Mismatch in Valve-in-Valve with a Supra-Annular Valve.

Transcatheter aortic valve replacement (TAVR) for a degenerated surgical bioprosthesis (valve-in-valve [ViV]) has become an established procedure. Elevated gradients and patient-prosthesis mismatch (PPM) have previously been reported in mixed TAVR cohorts. We analyzed our single-center experience using the third-generation self-expanding Medtronic Evolut R prosthesis, with an emphasis on the incidence and outcomes of PPM. This is a retrospective analysis of prospectively collected data from our TAVR database. Intraprocedural and intrahospital outcomes are reported. Eighty-six patients underwent ViV-TAVR with the Evolut R prosthesis. Mean age was 75.5 ± 9.5 years, 64% were males. The mean log EuroScore was 21.6 ± 15.7%. The mean time between initial surgical valve implantation and ViV-TAVR was 8.8 ± 3.2 years. The mean true internal diameter of the implanted surgical valves was 20.9 ± 2.2 mm. Post-AVR, 60% had no PPM, 34% had moderate PPM, and 6% had severe PPM. After ViV-TAVR, 33% had no PPM, 29% had moderate, and 39% had severe PPM. After implantation, the mean transvalvular gradient was reduced significantly from 36.4 ± 15.2 to 15.5 ± 9.1 mm Hg (p < 0.001). No patient had more than mild aortic regurgitation after ViV-TAVR. No conversion to surgery was necessary. Estimated Kaplan-Meier survival at 1 year for all patients was 87.4%. One-year survival showed no significant difference according to post-ViV PPM groups (p = 0.356). ViV-TAVR using a supra-annular valve resulted in low procedural and in-hospital complication rates. However, moderate or severe PPM was common, with no influence on short-term survival. PPM may not be a suitable factor to predict survival after ViV-TAVR.

Stress exercise haemodynamic performance and opening reserve of a stented bovine pericardial aortic valve bioprosthesis.

Despite unusual high rates of patient-prosthesis mismatch (PPM), excellent midterm clinical outcomes have been reported after surgical aortic valve replacement (SAVR) with the Avalus™ bioprosthetic valve (Medtronic). To elucidate this "PPM conundrum," the Avalus valve haemodynamics were assessed during exercise testing. Of the 148 patients who had undergone SAVR with the Avalus valve at our institution, 30 were randomly selected among those in whom stress test was deemed feasible and underwent a resting transthoracic echocardiography immediately followed by exercise echocardiography. Severe PPM was defined as indexed effective orifice area (iEOA) 0.65 cm2 /m2 and moderate PPM as iEOA 0.65 and 0.85 cm2 /m2 . Measured PPM was determined with the use of the measured iEOA at rest or stress, while the estimated PPM was based on the estimated iEOA, derived from the mean EOA reported for each valve size in the manufacturer chart. Measured EOA significantly increased from rest to peak exercise in all PPM groups (p < .05) and the rates of moderate and severe measured PPM decreased from 40% and 20% to 27% and 0%, respectively. The patients with low-flow state (flow < 250 ml/s) had significantly lower measured rest EOA (p = .03). On the basis of the estimated iEOA, there was no severe PPM and 19 patients had moderate PPM (63.3%), with a significantly lower opening reserve than the patients without estimated PPM (p = .04). The estimated iEOA was more reliably correlated to the measured iEOA at maximal stress than the measured iEOA at rest, especially in patients with a low-flow state. This study supports the concept of an opening reserve of the Avalus valve to explain the PPM conundrum and promotes the use of exercise Doppler-echocardiography to complete the assessment of mismatch, especially in patients with a low-flow state. Published estimated EOA seems reliable to predict the haemodynamic performance of the Avalus valve, whether the flow conditions at rest.

508 Incidence and determinants of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted indexed effective orifice area

Abstract Aims A small effective orifice area (EOA) by body surface area (BSA), defined as prosthesis–patient mismatch (PPM), is associated with elevated transprosthetic pressure gradients, less ventricular remodelling, and a worse prognosis. Calculating PPM by dividing the normal reference value of EOA for the model and size of the prosthetic valve (predicted PPM), instead of using the continuity equation has been recently confirmed as more accurate after trans catheter aortic valve intervention (TAVI), providing a stronger association with post-procedural haemodynamic outcomes. However, current evidence using this new definition is still limited, thus impairing generalizability. Accordingly, this analysis aims to extend such evidence providing incidence, and determinants of predicted PPM (PPMp) in an all-comers population undergoing TAVR with a high prevalence of self-expandable devices. Methods 395 patients who underwent TAVI at our Institution from September 2008 to November 2020 were included in this analysis. PPMp was then classified as moderate if ≤ 0.85 cm2/m2 and severe if ≤ 0.65 cm2/m2 as well as moderate if ≤ 0.70 cm2/m2 and severe if ≤ 0.55 cm2/m2 for patients with a body mass index &amp;gt; 30, as recommended by the Valve Academic Research Consortium-3 definition. The independent association between baseline clinical and procedural variables and the presence of moderate or severe PPMp was investigated with cross-sectional logistic regression analysis. Results 11 patients (2.78%) had severe and 33 (8.35%) moderate PPMp. Patients with moderate or severe PPMp (m/s PPMp) were younger, female, with a higher prevalence of hypercholesterolaemia, prior aortic valve implantation and balloon expandable device and lower prevalence of chronic obstructive disease (COPD). Post-procedural mean gradient was higher in patients with m/s PPMp. The independent clinical and procedural correlates associated with higher likelihood of m/s PPMp were valve in valve procedure (ViV) and the use of a balloon-expandable device. Conclusions Moderate or severe PPMp was observed only in a small part of patients underwent TAVI, leading, however, a higher post-procedural mean gradient compared to those without PPMp. Balloon expandable devices and ViV were the strongest determinant of moderate or severe PPM.

Abstract 13118: Sex Disparities in Hemodynamics and Outcomes Among Women Undergoing Contemporary Transcatheter Aortic Valve Replacement

Introduction: Several studies have demonstrated worse outcomes following transcatheter aortic valve replacement (TAVR) in women compared to men using early transcatheter heart valves (THV). Different THV designs impact hemodynamics in patients with small annuli and women constitute the majority of these patients. Hypothesis: We hypothesized that women represent the majority of patients with small annuli resulting in worse hemodynamics. Methods: We examined patients with symptomatic severe aortic stenosis who underwent TAVR using contemporary THVs across all surgical risk categories. We compared baseline characteristics, procedural details, in-hospital outcomes, and hemodynamics (30-day) according to sex. We then performed a secondary analysis focusing on the female patients, dichotomizing them based on aortic annular area above or below 430mm 2 . Results: Included were a total of 869 patients who underwent TAVR using a contemporary THV. The majority of patients with an annular area &lt;430mm 2 were female (82.5%) and most with an annular area &gt;430mm 2 were male (76.8%). Females saw a trend towards higher 30-day (1.5% vs. 0.6%; p=0.313) and 1-year (4.1% vs. 2.7%; p=0.265) mortality. Females with an annular area &lt;430mm 2 who received an self-expanding THV saw lower mean gradients at 30 days compared to those who received a balloon-expandable THV (8.0mmHg vs. 13.8mmHg; p&lt;0.001) which resulted in lower rates of moderate patient prosthesis mismatch (PPM) (21.2% vs. 73.6%; p&lt;0.001). A similar trend was seen in females with an annular area &gt;430mm 2 who received a self-expanding THV (9.3mmHg vs. 11.5mmHg; p&lt;0.001) which resulted in lower rates of moderate PPM as well (24.5% vs. 59.2%; p&lt;0.001). Conversely, female patients who received a self-expanding THV saw higher rates of permanent pacemaker implantation regardless of annular size. Conclusions: Female patients undergoing contemporary TAVR saw numerically higher short-term mortality which could be, a result of higher rates of PPM. These findings were more pronounced in the subset of females with small aortic annuli, where those who received a self-expanding THV demonstrated superior hemodynamics but at the cost of increased rates of permanent pacemaker implantation.

The Impact of Energy Loss Index and Body Mass Index on Prosthesis Patient Mismatch

ABSTRACT Background: Prosthesis-patient mismatch (PPM) occurs following transcatheter aortic valve replacement (TAVR) with conflicting data on prognosis. It is considered present when the echocardiographic-derived indexed aortic valve area (iAVA) is <0.85 cm2/m2 and severe when <0.65 cm2/m2. Pressure recovery, not accounted for in the continuity equation, leads to an overestimation of the incidence and severity of PPM, but can be corrected for using the energy loss index (ELI). This study seeks to determine the impact of pressure recovery on the incidence and severity of PPM by ELI. Methods: This retrospective study included consecutive patients undergoing TAVR from October 2014 through December 2019. Based on the iAVA values, patients were placed into categories of no PPM (>0.85 cm2/m2), moderate PPM (0.65-0.85 cm2/m2), or severe PPM (<0.65 cm2/m2). The iAVA and ELI were obtained by iAVA = (AVA/BSA) and ELI = (AVA x ascending aortic area)/((ascending aortic area - AVA) x BSA). We compared the incidence of PPM when using ELI versus iAVA with kappa analysis to verify agreement. Categorical variables were reported as n(%) and continuous variables as mean ± SD. Results: This study included 324 patients. The incidence of severe PPM decreased using iAVA vs. ELI with poor to moderate agreement: no PPM – 73% iAVA vs. 88% ELI (κ = 0.54), moderate PPM – 13% iAVA versus 6.5% ELI (κ < 0), severe PPM – 14% iAVA vs 5.5% ELI (κ = 0.52). Conclusions: Our study concludes that using ELI-based vs iAVA-based definition of PPM decreases the reported incidence and severity of PPM post-TAVR. Abbreviations: AVA: aortic valve area; AoA: ascending aortic area; BEV: balloon-expandable valve; BSA: body surface area; EACVI: European Association of Cardiovascular Imaging; ELI: energy loss index; ELCo: energy loss coefficient: iAVA: indexed aortic valve area; LVOT: left ventricular outflow tract; LVOTD: left ventricular outflow tract diameter; LVOTTVI: LVOT time velocity integral; PPM: Prosthesis-patient mismatch; PLAX: parasternal long axis; SAVR: surgical aortic valve replacement; SEV: self-expanding valve; STJ: sinotubular junction; TAVR: transcatheter aortic valve replacement; Vmax: peak aortic velocity; VTI: time-velocity integral

Prosthesis-patient mismatch affects late survival after valve surgery for severe aortic stenosis.

The effect of prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) in patient with symptomatic severe aortic stenosis (AS) remains unclear. Also, late follow-up in previous studies is confined to only one decade. We aimed to determine the effect of PPM on late survival after isolated AVR for symptomatic severe AS during 25 years of follow-up. In this retrospective cohort study, Kaplan-Meier survival analysis was performed to determine late survival in 404 consecutive patients with moderate PPM (N.=86), severe (N.=11), or no/mild PPM (N.=307) after isolated AVR for symptomatic severe AS during a mean follow-up of 25.0±2.9 years. Moderate, severe, and no/mild PPM were defined as indexed effective orifice area of >0.65≤0.85, ≤0.65, and >0.85 cm2/m2, respectively. Multivariable analysis was performed to identify possible independent predictors of decreased late survival, including moderate or severe PPM. Late survival of patients with severe PPM was worse in comparison with those with no/mild PPM: 7.4±2.6 (95% confidence interval 2.2-12.5) vs. 13.6±0.5 (95% confidence interval 12.6-14.6) years, respectively; P=0.020. Late survival of patients with moderate PPM was similar to those with no/mild PPM. Severe PPM was an independent predictor of decreased late survival: hazards ratio 4.002 (95% confidence interval 1.869-8.569); P<0.001. Moderate PPM was not an independent predictor of decreased late survival. Severe PPM was independently associated with decreased late survival after isolated AVR for symptomatic severe AS during a mean follow-up of 25.0±2.9 years. Therefore, severe PPM should be prevented as much as possible.

Serial echocardiographic evaluation of the Perimount Magna Ease prosthesis.

BackgroundThe Carpentier-Edwards Perimount Magna Ease prosthesis (PME) represents the latest generation of stented bioprostheses used for surgical aortic valve replacement (SAVR). The aim of our study was to evaluate the long-term clinical outcome and hemodynamic performance of the prosthesis with a focus on the incidence and course of structural valve deterioration (SVD) by serial echocardiographic examinations.MethodsSAVR with the PME was performed in 58 consecutive patients between 2007 and 2008. Transthoracic echocardiography was performed preoperatively, at discharge and annually during a 10-year follow-up at the German Heart Center Munich.ResultsMean age at surgery was 62±14 years. At discharge (n=57), the overall mean pressure gradient (MPG) and effective orifice area (EOA) were 15.8±4.1 mmHg and 1.8±0.4 cm2, respectively. Moderate patient-prosthesis mismatch (PPM) was present in 18 patients (32%) and severe PPM in 6 patients (11%) at discharge. Ten years following SAVR (n=33), the overall MPG was 16.6±7.3 mmHg and EOA was 1.3±0.4 cm2.Thirty-day and late mortality was 2% (n=1) and 21% (n=12), respectively. Survival at 1, 5, and 10 years was 94.7%±3.3%, 91.1%±4.1%, and 77.3%±5.9%, respectively. Freedom from reoperation at 10 years was 88.8%±4.7%. Ten years after PME implantation the cumulative incidence of any SVD, severe SVD, and bioprosthetic valve failure (BVF) was 25%±6%, 14%±5%, and 16%±5%, respectively.ConclusionsThe PME shows an excellent hemodynamic performance over the course of 10 years with development of clinically relevant SVD as late as 6 years post implant, and a 10-year incidence of severe SVD of 14%.

Early outcomes of patient-prosthesis mismatch following aortic valve replacement.

Introduction:Patient-prosthesis mismatch (PPM) has been associated with numerous short- and long-term adverse events. This study aimed to evaluate the effect of PPM on early postoperative results after aortic valve replacement (AVR) in daily practice.Methods:In this single-centre retrospective study, 150 non-consecutive patients from March 2019 to January 2020 with clinically indicated AVR with/without concomitant surgery were analysed. The study protocol included operative mortality, complication rate, and pre- and postoperative echocardiographic data. PPM was considered severe with indexed effective orifice area at <0.65 cm2/m2, moderate at 0.65–0.85 cm2/m2 and none at >0.85 cm2/m2.Results:Moderate PPM was observed in 16 patients (10.6%). No patient had severe PPM. PPM was not related to early mortality (r = 0.40, p = 0.630), intra- (r = −0.076, p = 0.352) and postoperative (r = −0.0134, p = 0.102) events.Conclusion:In this study, moderate PPM was a frequent finding after AVR, whereas severe PPM was not observed. PPM did not affect the early results after AVR. A long-term follow-up study in a large patient population is required to assess the actual influence of residual PPM.

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

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. 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. 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. 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.

Mid-term clinical and health-related quality of life outcomes for the Trifecta bioprosthesis.

The Trifecta valve has been reported to have excellent hemodynamics. Controversy exists on occurrence of patient-prosthesis mismatch (PPM) and data on mid-term outcome is sparse. Health-related quality of life (HRQoL) assessment for the Trifecta valve has not been reported before. The aim of this study was to report the mid-term clinical and HRQoL outcomes in patients undergoing Trifecta valve implantation at our institution. In this prospective, observational study, patients undergoing an aortic valve replacement (AVR) using the Trifecta valve were included. Data collection was retrospective from prospectively collected institutional database. Clinical and echocardiographic data were collected prospectively during follow-up. Quality of life was assessed using the Short Form-36 (SF-36) questionnaire. Forty-seven patients were included in the study of which 9 (19%) were women. Isolated AVR was carried out in 33 (70%) patients. In-hospital mortality and 30-day mortality were 1 (2.1%) and 2 (4.2%), respectively. With a mean indexed effective orifice area (iEOA) 0.96 ± 0.1, none of the patients had severe PPM. Moderate PPM was seen in 19%. The mean follow-up was 3 ± 1.7years. The 5-year survival estimate was 83.2% in the overall cohort, 81.4% in the isolated and 87.5% in the concomitant procedure group. Freedom from re-operation and structural valve degeneration at 5years was 95.7% and 97.8%. The mean physical health composite was 69.24 ± 2 and the mean mental health composite was 69.7 ± 25, indicating excellent mental and physical well-being among patients. The Trifecta valve provides satisfactory hemodynamics, survival and freedom from re-operation and excellent HRQoL at mid-term follow-up.

Incidence and predictors of prosthesis–patient mismatch after TAVI using SAPIEN 3 in Asian: differences between the newer and older balloon-expandable valve

BackgroundThe balloon-expandable SAPIEN 3 (S3) is superior to the older-generation balloon-expandable SAPIEN XT (XT) in a lower incidence of paravalvular aortic regurgitation, lower complication rates and better survival in transcatheter...

Can Moderate Patient Prosthesis Mismatch Be Tolerated in a Selected Group of Patients with Aortic Valve Replacement?

In this study, we aimed to determine the incidence of patient prosthesis mismatch (PPM) and its effects on ejection fraction (EF), gradients, and late survival. 200 patients who underwent isolated mechanical AVR between March 2013 and May 2016 were retrospectively evaluated based on patient records. 200 patients were included in the study. No PPM was detected in 42 (21%) patients, moderate PPM in 122 (61%), and severe PPM in 36 (18%) patients. A significant decrease was found in all groups in terms of mean valve gradients and LVMI (preoperative LVMI compared with postoperative LVMI at the 12th month) (P < .001). A 30% decrease in mean LVMI in the no PPM and moderate PPM groups and a 20% decrease in the severe PPM group were detected at the 6th month. In our postoperative data, we found that EF was preserved, the transvalvular gradient reduced, and LVMI decreased. There was no difference in mortality rates between the control (no PPM) group and the moderate PPM group. Taking into account our patient groups, we can say that no-to-moderate PPM has no major effect on left ventricular remodeling in patients with preserved left ventricular functions.

Prosthesis-patient mismatch after aortic valve in valve procedure: incidence, predictors and clinical outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Background. Transcatheter aortic valve-in-valve (TAVI ViV) implantation is an appealing treatment option for patients with degenerated bioprostheses. However, elevated residual gradients after TAVI ViV procedure are very common. These are an unwanted effects of prosthesis-patient mismatch (PPM). Currently, the actual incidenceof PPM, its predictors and its clinical outcomes have not been completely investigated. Purpose. The aims of this study was to investigate the incidence, predictors and clinical outcome of PPM and therefore of elevated gradients after TAVI ViV. Methods. 75 patients (age 78 ± 9 years, 36 male), who underwent TAVI-ViV due to failed aortic biological valve (60 stented, 15 stentless), were enrolled. Mechanism of bioprosthetic valve failure was stenosis (34 cases, 45%), regurgitation (24 cases, 32%) or combination (17 cases, 23%). Elevated residual gradients were defined as a mean DP&amp;gt; 20 mmHg. PPM was identified by the indexed effective orifice area (EOAi) measured by echocardiography (moderate PPM if 0.65 &amp;lt; EOAi &amp;lt; 0.85 cm²/m²; severe PPM if EOAi &amp;lt; 0.6 cm²/m²). Results. ViV TAVI was feasible in all patients, 33 patients (44%) were implanted with a balloon-expandable valve and 42 (56%) with a self-expandable valve. Post-procedural post-ballooning was performed in 16 out of 42 patients (38%) receiving a self-expandable valve. Post-operative mean DP&amp;gt; 20 mmHg was found in 35 patients (48%). Moderate PPM was found in 24 cases (33%) and severe PPM in 15 (20%). A logistic regression analyses identified small size of surgical prosthesis (size &amp;lt; 23 mm) [OR: 6.061(2.127-17.267), p = 0.001] and failed stented valve [OR: 20.727(2.522-170.364), p = 0.005] as independent predictors for the occurrence PPM. Interestingly PPM did not affect early and 1 years mortality (1 years mortality 1.3 %), while mortality was higher in pts with stentless prostheses (9%) Conclusions. PPM is a frequent finding after ViV procedures. Despite elevated residual gradients, TAVI ViV resolved prosthetic dysfunction and PPM did not affect mortality. Therefore, this procedure represents a promising new option for patients with failed biological prosthetic valves.

Left atrial dysfunction in patients with prosthesis-patient mismatch after transcatheter aortic valve replacement

Abstract Funding Acknowledgements Type of funding sources: None. Background. Transcatheter aortic valve replacement (TAVR) prostheses have better hemodynamics compared to surgical prostheses, with lower incidence of prosthesis-patient mismatch (PPM). Nonetheless, this complication is neither rare nor benign in the expanding population of TAVR patients (pts). Data regarding the effect of TAVR PPM on cardiac function is scarce. Our aim was to determine the short-term impact of PPM on left atrium (LA) function in patients undergoing transfemoral TAVR. Methods. One hundred forty-three consecutive pts (76.3 ± 7.5 yrs, 74 men) considered to be at high risk for SAVR were enrolled and examined before and 30 days after TAVR. All pts underwent a comprehensive echocardiogram, including speckle tracking echocardiography (STE) for LA and left ventricular (LV) strain analysis. Longitudinal LA strain parameters were assessed from the apical 4-chamber view. Peak values of global longitudinal LA strain (LAε) and LA systolic strain rate (SSr, reservoir function) and early diastolic strain rate (ESr, conduit function) were measured in all. Contractile LA function (late diastolic strain rate, ASr) was assessed in patients in sinus rhythm (106 pts). Results. Fifty-five pts (38%) had PPM (defined as an indexed effective orifice area, EOA ≤0.85 cm2/m2). Most of these pts (71%) had moderate PPM (indexed EOA between 0.65 and 0.85 cm2/m2). No significant differences in age (76.4 ± 8.1 vs 76.3 ± 7.2 yrs, p = 0.9), gender (p = 0.2), body surface area (p = 0.8), body mass index (p = 0.2) and the presence of cardiovascular risk factors (p &amp;gt; 0.2 for all) were observed between pts with and without PPM. The severity of post-TAVR aortic regurgitation was mild in 92 pts (64%) and moderate in 12 pts (8%) without any significant difference between pts with and without PPM. The post-TAVR prevalence of ³moderate mitral regurgitation was not different between the two groups (p = 0.40). After TAVR, there were no significant differences in terms of indexed LV mass, volumes, ejection fraction (p &amp;gt; 0.5 for all). LV global longitudinal strain was also similar between groups (-13.7 ± 4.3 vs -14 ± 3.6%, p = 0.7). Although LA volumes were similar between patients with and without PPM (47.8 ± 12.4 vs 49.3 ± 20.3 ml/m2, p = 0.6), in the mismatch-group we found a significantly reduced systolic global LA strain (12.7 ± 6.2 vs 15.9 ± 7.9%, p = 0.009) and impaired LA contractile function (ASr: -1.0 ± 0.4 vs -1.2 ± 0.5, p = 0.03). Parameters of LV diastolic function were also worse in the mismatch-group, with an E/e’sep ratio of 22 ± 10 vs 17 ± 7, p = 0.01. Conclusions. In our study group TAVR was associated with an incidence of PPM of 38%. The short-term follow-up of these patients revealed a significantly impaired LA function and increased LV filling pressure in patients with PPM compared to those without PPM. To our knowledge, this is the first report about the effect of PPM on the LA global and contractile function.

Prosthesis-patient mismatch is an independent predictor of congestive heart failure after transcatheter aortic valve replacement

Little is known about the effect of prosthesis-patient mismatch (PPM) on outcomes after transcatheter aortic valve replacement. We reported previously an increased risk of PPM with the SAPIEN 3 transcatheter heart valve (S3-THV). To investigate the association of PPM with 1-year outcomes in patients with severe aortic stenosis (AS) implanted with S3-THV. Moderate PPM was defined by an indexed effective orifice area (iEOA)≤0.85cm2/m2, and severe PPM by an iEOA<0.65cm2/m2. Inclusion criteria were severe symptomatic AS and implantation with S3-THV. The primary endpoint was hospitalization for congestive heart failure (CHF) at 1 year; the secondary endpoint was all-cause mortality. A total of 208 consecutive patients were included between 2016 and 2018. Male sex was prevalent (53.8%), mean age was 81.9±6.2 years, mean EuroSCORE II was 4.35±3.37, mean LVEF was 57.9±13%. Moderate and severe PPM were observed in 69 (33.2%) and 10 (4.8%) patients. Patients with PPM were younger (80.4±7 vs 82.8±5.41 years; P=0.006), had a larger BSA (1.84±0.19 vs 1.77±0.19 m2; P=0.01), a lower iEOA (0.73±0.08 vs 1.11±0.22 cm2/m2; P<0.001) and a higher mean gradient (14±4.6 vs 11.9±3.9mmHg; P<0.001). CHF occurred in 16.5% vs 7% (P=0.03). By multivariable analysis, PPM was independently associated with CHF (hazard ratio [HR] 3.17, 95% confidence interval [CI] 1.17 to 8.55; P=0.032), especially in patients with mitral regurgitation≥2/4 (HR>100, 95%CI>100 to>1000; P<0.01). PPM did not correlate with all-cause mortality (HR 0.90, 95%CI 0.22 to 3.03; P=0.86). PPM after S3-THV implantation is strongly associated with CHF at 1 year, but is not correlated with overall mortality.

Comparison of Transcatheter Aortic Valve Replacement between Self-Expanding versus Balloon-Expandable Valves in Patients with Small Aortic Annulus.

Background and ObjectivesTranscatheter aortic valve replacement (TAVR) has been reported as a good alternative for surgical aortic valve replacement in patients with small aortic annulus. Head-to-head comparisons of different transcatheter aortic valves in these patients are insufficient. We compared the outcomes after TAVR between two different types of recent transcatheter aortic valves (self-expanding vs. balloon-expandable) in patients with small aortic annulus.MethodsA total of 70 patients with severe aortic stenosis and small annulus (mean diameter ≤23 mm or minimal diameter ≤21 mm on computed tomography) underwent TAVR with either a self-expanding valve with supra-annular location (n=45) or a balloon-expandable valve with intra-annular location (n=25). The echocardiographic hemodynamic parameters after TAVR and 1-year follow-up were compared.ResultsBetween the self-expanding and balloon-expandable valve-treated patients, the clinical outcomes including permanent pacemaker implantation (11.1% vs. 8.0%), acute kidney injury stage 2 or 3 (4.4% vs. 4.0%), and major vascular complication (4.4% vs. 0.0%) were similar without all-cause mortality, stroke, and life-threatening bleeding during 30-day follow-up. Compared with the balloon-expandable valve-treated patients, the self-expanding valve-treated patients presented larger effective orifice area (EOA) (1.46±0.28 vs. 1.75±0.42 cm2, p=0.002) and indexed EOA (0.95±0.21 vs. 1.18±0.28 cm2/m2, p=0.001), whereas mean aortic valve gradient (11.7±2.9 vs. 8.9±5.2 mmHg, P=0.005) and incidence of ≥moderate prosthesis-patient mismatch (36.0% vs. 8.9%, p=0.009) were lower. These hemodynamic differences were maintained at 1-year follow-up.ConclusionsTAVR with self-expanding valves was associated with superior hemodynamic outcomes compared with balloon-expandable valves in patients with small aortic annulus.

Reclassification of prosthesis-patient mismatch after transcatheter aortic valve replacement using predicted versus measured indexed effective orifice area

The incidence and impact on outcomes of prosthesis-patient mismatch (PPM) have yielded to discrepant results between transcatheter aortic valve replacement (TAVR). The objective of this study was to compare the incidence and impact on outcomes of measured (PPM M ) versus predicted (PPM P ) PPM following TAVR. All consecutives patients who underwent TAVR between 2007 and 2018 were included. Effective orifice area (EOA) was measured by Doppler-echocardiography using the continuity equation and predicted according to the normal reference for each model and size of valve. PPM was defined using EOA indexed to body surface area (EOAi) as moderate if ≤ 0.85 cm 2 /m 2 and severe if ≤0.65 cm 2 /m 2 (respectively ≤ 0.70 cm 2 /m 2 and ≤ 0.55 cm 2 /m 2 if body mass index ≥ 30 kg/m 2 ). The outcome endpoints were high residual gradient (≥ 20 mmHg) and the composite of cardiovascular mortality and hospital readmission for heart failure at 1 year. Overall, 1088 patients underwent a TAVR (55% male, age 79.1 ± 8.4 years and STS score 6.6 ± 4.7%); balloon-expandable device was used in 83%. Incidence of moderate (10% vs. 27%) and severe (1% vs. 17%) PPM was markedly lower when defined by predicted versus measured EOAi ( P < 0.001). Balloon-expandable device implantation (OR: 1.90, P = 0.029) and valve-in-valve procedure ( n = 118; OR: 3.21, P < 0.001) were the main factors associated with PPM occurrence. Compared to measured PPM, predicted PPM showed stronger association with high residual gradient. Severe measured or predicted PPM was not associated with clinical outcomes ( Fig. 1 ). The utilization of the predicted EOAi reclassifies the majority of patients with PPM to no PPM following TAVR. Compared to measured PPM, predicted PPM had stronger association with hemodynamic outcomes, while both methods were not associated with clinical outcomes.

Early Hemodynamics after Aortic Valve Replacement.

Background and objectives: The aims of this study were to investigate changes in the hemodynamics associated with different types of aortic prostheses and to evaluate patient-prosthesis mismatch (PPM) at rest and after exercise. Materials and Methods: We retrospectively analyzed 150 patients who presented with indications for aortic valve replacement (AVR) with/without concomitant surgery from March 2019 to January 2020. The study population included 90 (60%) men and 60 (40%) women (mean age, 67.33 ± 10.22 years; range, 37–88 years). Echocardiography data such as peak and mean transprosthetic pressure gradients (Gmax, Gmean), velocity (V), effective orifice area (EOA), and indexed EOA (iEOA) were derived at rest and after exercise at baseline and before discharge. The study patients performed the six-minute walk test (6MWT) on the 5th–7th postoperative day. Results: Stented tissue valves showed excellent performance at rest and after exercise in comparison with mechanical valves, which showed favorable hemodynamics at rest only. At the time of discharge, moderate PPM was observed in 7/74 patients (9.5%) at rest and 5/98 (3.3%) patients after exercise. None of the patients showed severe PPM. EOA and iEOA were not significantly different between the groups. However, the stented group showed more pronounced changes in EOA and iEOA after exercise, whereas the changes in the mechanical valve group did not reach significance. Conclusions: In the early postoperative period, mechanical valves and stented valves showed favorable resting hemodynamics. The PPM rate measured after exercise was lower than that at rest.

Abstract 16029: Patient Prosthesis Mismatch Post Transcatheter Aortic Valve Replacement is Associated With Lack of Improved Left Ventricular Diastolic Function

Background: Patient prosthesis mismatch (PPM) is a frequent problem after transcatheter aortic valve replacement (TAVR) that results in adverse cardiac remodeling. This study sought to evaluate the association between PPM and changes in diastolic function post-TAVR. Methods: 339 patients (79.3+8.8 y, 44.4% female) who underwent TAVR for severe aortic stenosis between 2015-2018 with an echocardiogram (echo) at baseline and at 1-year were studied. Echo measurements were performed according to ASE guidelines. Moderate PPM is defined by an indexed effective orifice area (iEOA) of &lt;0.85 to &gt;0.65 cm 2 /m 2 , and severe PPM by an iEOA &lt;0.65 cm 2 /m 2 . The aortic valve acceleration to ejection time ratio (AT/ET) was measured to further stratify patients with PPM and considered abnormal if &gt;0.35. Student’s t-tests were used to compare diastolic function at baseline and 1-year. Results: We found that 26.2% of subjects had moderate PPM, 11.8% had severe PPM, and 8.3% had an AT/ET &gt;0.35 (Table 1). Tissue velocity at both the medial and lateral mitral annulus was reduced at baseline and did not improve. Left atrial pressure (LAP) as assessed by E/e` improved in those without PPM (19.5+9.5 to 18.8+9.6, p=0.04) and those with moderate PPM (21+12.2 to 18.2+6.9, p=0.03), but not in those with severe PPM or with AT/ET&gt;0.35. Right ventricular systolic pressure (RVSP) decreased significantly in patients with no or moderate PPM (39.6+13.6 mmHg to 35.5+10.8 mmHg, p=0.02 and 41.2+13.9 mmHg to 36+10.8 mmHg, p=0.006; respectively), while there was no significant decrease for patients with severe PPM or with AT/ET&gt;0.35. Conclusion: We found that in patients undergoing TAVR, diastolic function was impaired as evidenced by low mitral tissue velocities, elevated LAP, and elevated RVSP. PPM resulted in less improvement of diastolic parameters including no improvement in LAP and RVSP. These findings suggest that severe PPM has an adverse effect on cardiac remodeling.