Prosthesis-patient Mismatch Group Research Articles

Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement: Meta-Analysis of Kaplan-Meier–Derived Individual Patient Data

BackgroundIt remains controversial whether prosthesis-patient mismatch (PPM) (in general considered moderate if indexed effective orifice area is 0.65-0.85 cm2/m2 and severe when <0.65 cm2/m2) affects the outcomes after transcatheter aortic valve replacement (TAVR). ObjectivesThe purpose of this study is to evaluate the time-varying effects and association of PPM with the risk of overall mortality. MethodsStudy-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of studies published by December 30, 2021. ResultsIn total, 23 studies met our eligibility criteria and included a total of 81,969 patients included in the Kaplan-Meier curves (19,612 with PPM and 62,357 without PPM). Patients with moderate/severe PPM had a significantly higher risk of mortality compared with those without PPM (HR: 1.09 [95% CI: 1.04-1.14]; P < 0.001). In the first 30 months after the procedure, mortality rates were significantly higher in the moderate/severe PPM group (HR: 1.1 [95% CI: 1.05-1.16]; P < 0.001). In contrast, the landmark analysis beyond 30 months yielded a reversal of the HR (0.83 [95% CI: 0.68-1.01]; P = 0.064), but without statistical significance. In the sensitivity analysis, although the authors observed that severe PPM showed higher risk of mortality in comparison with no PPM (HR: 1.25 [95% CI: 1.16-1.36]; P < 0.001), they did not observe a statistically significant difference for mortality between moderate PPM and no PPM (HR: 1.03 [95% CI: 0.96-1.10]; P = 0.398). ConclusionsSevere PPM, but not moderate PPM, was associated with higher risk of mortality following TAVR. These results provide support to implementation of preventive strategies to avoid severe PPM following TAVR.

Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement in Asian Patients

BackgroundLittle is known about the incidence of prosthesis-patient mismatch (PPM) and its impact after transcatheter aortic valve replacement with self-expanding valves in an Asian population. We aimed to assess postprocedural effective orifice area with standardized methods and the impact of PPM on midterm outcomes after CoreValve or Evolut R (Medtronic) implantation in an Asian population. MethodsAmong 201 consecutive patients undergoing CoreValve or Evolut R implantation, PPM was assessed at 30 days and defined based on core laboratory measured indexed effective orifice area as severe (less than 0.65 cm2/m2) or moderate (0.65 to 0.85 cm2/m2). Multivariable regression models were utilized to examine predictors of PPM as well as mortality and rehospitalization for heart failure at midterm follow-up. ResultsModerate and severe PPM were observed after self-expanding valves in 37 patients (18.4%) and 3 patients (1.5%), respectively. These 40 patients were included in the PPM group. Predictors of PPM included female sex, larger body surface area, and lower left ventricular ejection fraction. At midterm (median 30.4 months; interquartile range, 17 to 57.8) follow-up, patients with PPM had an increased risk of all-cause death (adjusted hazard ratio 1.95; 95% confidence interval, 1.08 to 3.53; P = .027), cardiovascular mortality (adjusted hazard ratio 3.38; 95% confidence interval, 1.04 to 10.99; P = .043), and rehospitalization for heart failure (adjusted hazard ratio 2.40; 95% confidence interval, 1.11 to 5.17; P = .025). ConclusionsPatient-prosthesis mismatch was associated with higher midterm mortality and rehospitalization for heart failure in an Asian population. The expected postprocedural effective orifice area for any given valve size may be helpful in preprocedural decision making to avoid PPM.

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.

Impact of prosthesis-patient mismatch on early and late outcomes after mitral valve replacement: a meta-analysis.

BackgroundPrognostic significance of prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) remains uncertain because of the limited studies reporting inconsistent or even contrary results. This meta-analysis pooled results of all available studies comparing early and late prognoses between patients with significant mitral PPM and those without.MethodsStudies were identified by searching Pubmed, Excerpta Medica Database, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov. Impact of PPM on postoperative hemodynamic results, thirty-day mortality, overall mortality, mortality of thirty-day survivors, and primary morbidity after MVR was evaluated via meta-analysis. Robustness of pooled estimates, source of heterogeneity, and publication bias were assessed via sensitivity analyses, meta-regression as well as subgroup analysis stratified according to methodological or clinical heterogeneity, or sequential omission method, and funnel plot or Begg's and Egger's tests, respectively.ResultsNineteen cohort studies involving 9302 individuals (PPM group: n = 5109, Control group: n = 4193) were included for meta-analysis. Total PPM and severe PPM prevalence were 3.8%–85.9% and 1%–27%, with a mean value of 54.9% and 14.1%, respectively. As compared with control group, mitral PPM group demonstrated a poorer postoperative hemodynamic status of higher mean and peak residual transprosthetic pressure gradients (TPG), higher postoperative systolic pulmonary artery pressure (SPAP) and less reduction, higher postoperative pulmonary hypertension (PH) prevalence and less PH regression, smaller net atrioventricular compliance, less NYHA class decrease, higher postoperative functional tricuspid regurgitation prevalence and less regression. The PPM group also revealed a higher thirty-day mortality, long-term overall mortality, mortality of thirty-day survivors, and postoperative congestive heart failure prevalence, which were positively correlated with the severity of PPM if it was classified into tri-level subgroups. Left ventricular end-diastolic diameter, postoperative atrial fibrillation (AF) prevalence, and the AF regression were analogous between groups. Most pooled estimates were robust according to sensitivity analyses. Male patients and bioprosthesis implantation proportion were prominent source of between-study heterogeneity on thirty-day mortality. Publication bias was not significant in tests for all the outcomes, except for SPAP and TPG.ConclusionsMitral PPM would result in poorer postoperative hemodynamics and worse early and late prognosis. Severe PPM must be avoided since deleterious impact of mitral PPM was severity dependent.

Prosthesis-Patient Mismatch Increases Early and Late Mortality in Low Risk Aortic Valve Replacement

The concept of prosthesis-patient mismatch (PPM) has gained much attention since first described 40 years ago. Previous studies have shown conflicting evidence regarding increased early and late morbidity and mortality with PPM after aortic valve replacement (AVR). The aim of this study was to evaluate the effects of PPM on short- and long-term mortality in low-risk patients after isolated AVR. A retrospective, single-center study involving 1707 consecutive patients ≤80 years of age with preserved left ventricular systolic function who underwent elective, primary isolated AVR operations from 2008 to 2018. Patients were stratified into 2 groups according to the presence of PPM (n = 96), defined as effective orifice area index <0.85 cm2/m2 body surface area, and no-PPM (n = 1611). The effect of PPM on mortality was evaluated with univariate and multivariate analyses. 30-day mortality was 0.8% (4.2% in PPM group vs 0.6 in no-PPM group; P = 0.005). PPM occurred more in female gender, obese and older patients. PPM was highly associated with long-term all-cause mortality (median 4 years [Q1-Q3 2-7]; HR: 1.79, 95% CI: 1.27-2.55, P = 0.002), and remained strongly and independently associated after adjustment for other risk factors (HR: 1.60, 95% CI: 1.10-2.34, P = 0.014). In propensity score-matched analysis, the adjusted mortality risk was higher in PPM group (HR: 2.03, 95% CI: 1.22-3.39, P = 0.006) compared to no-PPM group. In a single-centre observational study, PPM increased early mortality and was independently associated with long-term all-cause mortality after low-risk, primary isolated AVR operations. Strategies to avoid PPM should be explored and implemented.

Evolution of concomitant moderate and moderate to severe functional mitral regurgitation, following aortic valve surgery for severe aortic stenosis

Background/Aim. Functional mitral regurgitation (FMR) is a common entity in patients with aortic stenosis (AS) undergoing aortic valve replacement (AVR). The aim of this study was to examine evolution of moderate and moderate to severe FMR after an isolated AVR, to identify prognostic indicators for persistent MR postoperatively, and to offer the recommendation regarding surgical intervention for moderate and moderate to severe FMR at the time of AVR for AS. Methods. We retrospectively reviewed 39 consecutive patients with moderate and moderate to severe FMR at the time of isolated AVR from January 2007 to December 2013. We collected preoperative and postoperative echocardiographic data to determine the evolution of FMR after AVR. Patients were divided into the persistent (n = 14) and improved FMR group (n = 25). Secondary division was into the prosthesis-patient mismatch (PPM, n = 7) and non prosthesis-patient mismatch group (non PPM, n = 32 patients). Late follow-up echocardiography was completed in 100% (39/39) of patients. Results. FMR improved postoperatively (MR ? 2+) in 64% (25/39) of patients, while 36% (14/39) of patients had persistent MR ? 2). In comparison to the persistent group, the patient with improved FMR had significant decrease in the left ventricular enddiastolic diameter, left ventricular end-systolic diameter, posterior wall and septum thickness postoperatively. The same indicators of reverse remodeling were found in the non PPM group in comparison to the PPM group. The incidence of postoperative FMR improvement was higher in the non PPM group (65.6%, p = 0.001) in comparison to the PPM group (42.9%, p = 0.125). The mean follow-up duration was 39.5 ? 23.5 months. Conclusion. In accordance with previous studies, this study also showed improvement in FMR following AVR surgery. Improvement in MR degree was associated with echocardiographic parameters of reverse left ventricular remodeling. Conservative approach is advisable in patients with moderate and moderate to severe FMR, believing that repair or replacement is unnecessary at the time of AVR for severe AS. PPM could prevent downgrading of FMR, stressing out the importance of choosing the prosthesis of adequate size.

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

Little is known about the impact of prosthesis-patient mismatch (PPM) on outcomes after trans-catheter aortic valve replacement (TAVR). We reported previously an increased risk of PPM with Sapien 3 transcatheter Heart valve (S3-THV). We aimed to investigate the one-year outcomes of patients operated on for severe aortic stenosis (AS) with S3-THV based on the occurrence of PPM. Indexed effective orifice area (iEOA) was estimated by post-procedural echocardiography(TTE). PPM was defined as moderate when 0.65 cm 2 ≤ Ieoa ≤ 0.85 cm 2 , or severe if iEOA < 0.65 cm 2 /m 2 . Inclusion criteria: severe symptomatic AS implanted with S3-THV. Primary endpoint: one-year overall mortality secondary endpoint: hospitalization for congestive heart failure (CHF). A total of 227 consecutives patients were included between January 2015 and December 2016. Of the 208 patients with complete follow-up, mean age was 81.9 ± 6, mean Euroscore2 was 4.35 ± 3.4, mean baseline LVEF was 58 ± 13%. At post-procedural TTE, moderate and severe PPM were observed in 69 (33%) and 10 (4.8%) patients respectively. Patients with PPM were younger (80.4 ± 7 vs. 82.9 ± 5, P = 0.007), had a larger body surface area (1.84 ± 0.19 vs. 1.77 ± 0.19, P = 0.01), a lower iEAO (0.73 ± 0.1 vs. 1.1 ± 0.2, P < 0.001) and a higher mean gradient (12 ± 4 vs. 14 ± 5 mmHg, P < 0.001). At 1 year, the estimated overall mortality was similar between the PPM and non PPM groups (5.1% vs. 5.4%, P = 0.97); the PPM group had a significantly higher incidence of CHF at one year follow-up (16.5% vs. 7%, P = 0.04). By multivariate analysis, PPM (HR = 2.4 [1.02–6], P = 0.04) independently predicted CHF whereas LVEF, Paravalvular leakage ≥1, age and male gender did not. By subgroup analysis, patients with MR ≥2 were more vulnerable to PPM as they experienced a prohibitive risk of CHF (HR = 51.4 [2.61–99], P = 0.006). PPM after TAVR with S3-THV is not a risk factor for midterm mortality but is an independent predictor of CHF, especially in the subset of patients with MR ≥2.

Incidence, Predictors, and Clinical Impact of Prosthesis–Patient Mismatch Following Transcatheter Aortic Valve Replacement in Asian Patients: The OCEAN-TAVI Registry

ObjectivesThe authors sought to investigate the prevalence, risk factors, and mid-term mortality in Asian patients with prosthesis–patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR). BackgroundLittle information is available on PPM after TAVR in Asian patients. MethodsThe authors included 1,558 patients enrolled in the OCEAN-TAVI (Optimized transCathEter vAlvular iNtervention) Japanese multicenter registry from October 2013 to July 2016 after excluding patients who died following TAVR before discharge. PPM was defined as moderate if ≧0.65 but ≦0.85 cm2/m2, or severe if <0.65 cm2/m2 at the indexed effective orifice area by post-procedural echocardiography. ResultsOf the 1,546 patients, moderate and severe PPM were observed in 138 (8.9%) and 11 (0.7%) patients, respectively. These 149 patients were included in the PPM group. The median age and body surface area were 85 years (interquartile range [IQR]: 81 to 88 years) and 1.41 m2 (IQR: 1.30 to 1.53 m2), respectively. In our multivariate analysis, younger age, larger body surface area, smaller aortic valve area, smaller annulus area, no balloon post-dilatation, and use of Edwards Sapien 3 (Edwards Lifesciences, Irvine, California) were identified as independent predictors of PPM. The estimated cumulative all-cause mortality at 1 year using the Kaplan-Meier method was similar between the PPM and non-PPM groups (10.2% vs. 8.3%; log-rank; p = 0.41). ConclusionsThe low prevalence of PPM and mortality at 1 year in patients with PPM after TAVR in this Japanese cohort implies that PPM is not a risk factor for mid-term mortality in Asian patients who have undergone TAVR.

Effect of prosthesis patient mismatch in mitral position on pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is associated with poor outcome after mitral valve replacement (MVR). We proposed to evaluate the effect of valve prosthesis patient mismatch (PPM) on pulmonary arterial (PA) pressure following MVR. Five hundred patients who have undergone MVR were studied retrospectively. Postoperative PA systolic pressure (PASP) measured 6 months postoperatively by Doppler echocardiography was compared with preoperative values. PASP ≥ 40 mmHg was defined as PAH. Mitral valve effective orifice area was calculated by the continuity equation and indexed for body surface area. PPM was defined as indexed effective orifice area ≤ 1.2 cm2/m2. A multivariate model was constructed to ascertain the independent determinants of systolic PA pressure. Also, a propensity score model was constructed to overcome the baseline differences between the PPM and no PPM groups. The incidence of PPM in this study was 37.2%. The average postoperative PASPs were 30.49 and 42.35 mmHg in the no PPM and PPM groups, respectively; (P < 0.001). Regression of PAH in the PPM and no PPM groups was 76.26% and 20.64%, respectively; (P < 0.001). The indexed effective orifice area correlated well with postoperative PASP (r = 0.71). The overall survival and freedom from cardiac death at 10 years were 79.8% and 85.3%; and at 20 years were 66.5% and 74.3%, respectively. Both, overall survival and the freedom from cardiac death were higher in the no PPM group than in the PPM group; (P < 0.001). Propensity score matching analysis yielded 112 pairs of the PPM and no PPM cohorts, which revealed higher overall survival and freedom from cardiac death in the no PPM group; (P = 0.028 and 0.012, respectively). Mitral PPM is an independent predictor of persistent PAH after MVR along with associated morbidity and reduced survival.

Effect of Patient-Prosthesis Mismatch in Aortic Position on Late-Onset Tricuspid Regurgitation and Clinical Outcomes after Double Valve Replacement.

PurposeSignificant late-onset tricuspid regurgitation (TR) is unfortunately common after double valve replacement (DVR); however, its underlying factors remain undefined. We evaluated the effect of aortic patient-prosthesis mismatch (PPM) on late-onset TR and clinical outcomes after DVR.Materials and MethodsOf the 2392 consecutive patients who underwent aortic valve replacement between January 1990 and May 2014 at our institution, we retrospectively studied 462 patients who underwent DVR (excluding concomitant tricuspid valvular annuloplasty or replacement). Survival and freedom from grade >3 TR were compared between PPM (n=152) and non-PPM (n=310) groups using the Kaplan-Meier method.ResultsAlthough the overall survival rates were similar between the two groups at 5 and 10 years (95%, 91% vs. 96%, 93%, p=0.412), grade >3 TR-free survival was significantly lower in the PPM group (98%, 91% vs. 99%, 95%, p=0.014). Small body-surface area, atrial fibrillation, PPM, and subaortic pannus were risk factors for TR progression. However, aortic prosthesis size and trans-valvular pressure gradient were not significant factors for either TR progression or overall survival.ConclusionAortic PPM in DVR, regardless of mitral prosthesis size, was associated with late TR progression, but was not significantly correlated with overall survival. Therefore, we recommend careful echocardiographic follow-up for the early detection of TR progression in patients with aortic PPM in DVR.

Impact of Prosthesis-Patient Mismatch on Long-term Functional Capacity After Mechanical Aortic Valve Replacement

BackgroundThe impact of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) for aortic stenosis on exercise capacity remains controversial. The aim of this study was to analyze the long-term impact of PPM after mechanical AVR on maximal oxygen uptake (VO2max). MethodsThe study included 75 patients who had undergone isolated mechanical AVR for aortic stenosis with normal left ventricular (LV) function between 1994 and 2012. Their functional capacity was evaluated on average 4.6 years after AVR by exercise testing, including measurement of their VO2max, and by determining their New York Heart Association functional class and Short Form-36 score. Two groups were defined by measuring the patients' indexed effective orifice area (iEOA) by transthoracic echocardiography: a PPM group (iEOA < 0.85 cm2/m2) and a no-PPM group (iEOA ≥ 0.85 cm2/m2). ResultsPPM was present in 37.0% of the patients. The percentage of the predicted VO2max achieved was significantly lower in the PPM group (86.7 ± 19.5% vs 97.5 ± 23.0% in the no-PPM group; P = 0.04). Compared with the no-PPM group, the PPM group contained fewer patients in New York Heart Association functional class I and their mean Short Form-36 physical component summary score was significantly lower. The mean transvalvular gradient was significantly higher in the PPM group than in the no-PPM group (P < 0.001). Systolic and diastolic function and LV mass had normalized in both groups. ConclusionsPPM is associated in the long term with moderate but significant impairment of functional capacity, despite optimal LV reverse remodelling and normalization of LV systolic and diastolic function.

Patient-Prosthesis Mismatch After Mitral Valve Replacement: A Propensity Score Analysis

We evaluated the impact of patient-prosthesis mismatch (PPM) after mitral valve replacement on the clinical outcomes using propensity score models. In all, 760 patients (aged 51 ± 12 years; male:female= 252:508) in whom mitral valve replacement wasperformed using three types of mechanical valves and two types of bioprosthetic valves were enrolled. Invivo data of effective orifice area was drawn from literatures and mitral PPM was defined as an effective orifice area index 1.2 cm(2)/m(2) or less. The propensity score model was used in two ways: the inverse probability of treatment weighting-adjusted multivariable analyses, and 1:1 propensity score matching. The duration of the follow-up was 127 months (range, 1 to 276). Mitral PPM was identified in 19.3%. The patients with PPM (PPM group, n= 147) were older and had more comorbidities than the patients without PPM (non-PPM group, n= 613). The 10-year and 20-year overall survival and freedom from cardiac death were 83.5% and 71.3%, respectively, for the PPM group; and 90.2% and 83.1%, respectively, for the non-PPM group. The inverse probability of treatment weighting-adjusted multivariable analyses demonstrated that mitral PPM is a significant risk factor for overall survival (hazard ratio 1.681, 95% confidence interval: 1.139 to 2.482) and freedom from cardiac death (hazard ratio 1.673, 95% confidence interval: 1.012 to 2.765). The propensity score matching extracted 68 pairs. Both overall survival and freedom from cardiac death were also higher in the propensity score-matched non-PPM group than in the PPM group (p= 0.039 and p= 0.017, respectively). Mitral PPM significantly affects long-term outcomes after mitral valve replacement in terms of long-term survival and freedom from cardiac death.

Rapid Deployment of Aortic Bioprosthesis in Elderly Patients With Small Aortic Annulus

Aortic valve replacement in elderly patients with a small aortic annulus remains challenging. Patient-prosthesis mismatch (PPM) should be prevented without impacting operative mortality. Hemodynamic benefits resulting from rapid-deployment aortic valve replacement with the Edwards Intuity bioprosthesis for this indication were evaluated. Elective patients with severe aortic stenosis who required an Edwards Intuity bioprosthesis, size 19 mm and 21 mm, were prospectively included between July 2012 and July 2014. Transthoracic echocardiography was performed preoperatively and at 1-month follow-up. Sixty-six consecutive patients (mean age, 78 ± 6.4 years; 54.5% women) were included. The Intuity 19 mm was inserted in 29 patients, and the Intuity 21 mm was inserted in 37 patients. No deaths or aortic annulus ruptures occurred. Mean aortic cross-clamp time was 42.7 ± 18.2 minutes. At the 1-month follow-up, mean New York Heart Association classification was 1.6 ± 0.5 versus 2.2 ± 0.8 (p < 0.001). The mean gradient decreased from 59 ± 17.6 mm Hg to 13.7 ± 4.4 mm Hg (p < 0.001). Mean indexed effective orifice area was 0.77 ± 0.17 cm(2)/m(2) for the Intuity 19 mm and 1.01 ± 0.32 cm(2)/m(2) for the Intuity 21 mm. Twenty-one patients (32%) had a moderate PPM (indexed effective orifice area < 0.85 cm(2)/m(2)), and 10 patients (15%) had a severe PPM (indexed effective orifice area < 0.65 cm(2)/m(2)). The mean gradient was 15.1 ± 3.5 mm Hg and 16.9 ± 4.9 mm Hg in the moderate PPM group and severe PPM group, respectively (p = 0.3). The left ventricular mass index dramatically decreased from 153.2 ± 32.7 g/m(2) to 118.4 ± 20.2 g/m(2) (p < 0.001), and only 1 patient (1.5%) had a periprosthetic regurgitation greater than 1. Regarding the low rate of severe PPM and the early regression of left ventricular mass, these preliminary studies indicate the potential benefit of the Intuity bioprosthesis in patients with a small aortic annulus. Midterm results should be evaluated.

Prosthesis-patient mismatch and left ventricle systolic strain in patients with severe degenerative aortic stenosis, who are undergoing surgical valve replacement

Prosthesis-patient mismatch (PPM) is an independent predictor of post-operative mortality after aortic valve replacement (AVR), particularly when it is associated with a left ventricle (LV) dysfunction. Two-dimensional speckle-tracking echocardiography (2D-STE) could be useful in assessing LV function in patients with PPM. To evaluate the impact of PPM on myocardial multidirectional LV systolic strain in patients who are undergoing AVR for severe degenerative aortic stenosis (AS). Sixty-five patients (38 females, 27 males, age: 69.9 ± 9.1 years) with severe degenerative AS and preserved LV ejection fraction were enrolled into the study. Pre- and three-month postoperative 2D-STE was performed to assess LV peak systolic longitudinal strain (LV PSLS), circumferential strain, and LV rotation. The indexed prosthesis effective orifice area (iEOAprosth) was used to define PPM (≤ 0.65 cm2/m2), and it was used to distinguish the study groups: PPM (+) (n = 35) and PPM (-) (n = 30). A significant association of LV PSLS and interaction in the groups [PPM (+) vs. PPM (-)] and intervention (before vs. after AVR; p = 0.019) was observed - the lowest value of LV PSLS was in the PPM (+) group (-14.9 ± 3.5%) after AVR. A significant difference in the mean delta (before/after AVR) values of LV PSLS (0.7 ± 3.1% vs. -1.2 ± 3.6%; p = 0.04) in the PPM (+) vs. the PPM (-) groups was found. LV PSLS correlated with iEOAprosth (r = -0.520, p < 0.001) that was obtained three months after AVR. The occurrence of PPM in patients undergoing AVR for severe degenerative AS was associated with reduced LV PSLS in a three-month observation.

Patient-prosthesis mismatch increases the mean platelet volume in patients with aortic valve replacement.

Patient-prosthesis mismatch (PPM) is defined when the ratio of the effective orifice area of the normally functioning prosthetic valve to the body surface area of the patient is <0.85 cm(2)/m(2). The aim of this study was to assess the measurements of the mean platelet volume (MPV) as an indicator of platelet activation in patients with PPM. A total of 109 patients with isolated aortic valve replacement (AVR) procedures with a mechanical prosthesis and a control group from a normal population of 102 people compatible in terms of age and sex were chosen for the study. The AVR group was subdivided into a PPM group (n = 41) and non-PPM group (n = 68). All patients and control participants underwent echocardiographic examinations, with simultaneous measurements of the serum MPV values. The MPV measurements were significantly higher in the patients with AVR compared to the control group (8.97 ± 0.93 vs. 8.26 ± 0.14, p < 0.001). Higher results were also obtained in the patients with PPM compared to the non-PPM group (9.36 ± 0.61 vs. 8.73 ± 1.01, p < 0.001). The platelet counts were found to be similar in both groups (p > 0.05). We have herein shown that the PPM patients had a significantly higher MPV compared to the patients with AVR without PPM and healthy subjects.

Prevalence and impact of prosthesis-patient mismatch in patients with paradoxical low-flow severe aortic stenosis

Purpose: Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) (indexed stroke volume 50%, have worse outcome compared to those with AS but normal flow. Moreover, Prosthesis-Patient Mismatch (PPM) (indexed prosthetic valve effective orifice area< 0.85cm2/m2) after aortic valve replacement (AVR) is a predictor of higher mortality. However, the impact of PPM in patients with PLFAS on long-term survival is unknown. Our aim was to analyze the prevalence and the impact on long-term survival of PPM in patients with PLFAS. Methods: 667 consecutive patients (age 74±8 years, 42% female, AVA 0.69±0.16 cm2) with preserved LVEF who underwent AVR for severe AS at our institution between 2000 and 2010 were included in this study. Patients were divided into 4 groups according to the presence/absence of PLF at cardiac catheterization and presence/absence of PPM following AVR and we compared short and long-term survival between these groups. Results: Among the 667 patients, 26% had PLFAS and PPM occurred in 54% of patients after AVR. Compared to patients with no PLF & no PPM (36% of the total cohort), those with PLF & PPM (15%) were significantly older, with more comorbidities. The 30-day mortality did not differ between the PLF- PPM and no-PLF-no PPM group. The 10-yr survival rate was significantly reduced in the PLF-PPM (37±9%) group compared to no PLF-no PPM (70±5%; p=0.003). In multivariate analysis adjusting for all predictors of survival, concomitant presence of PLF & PPM was an independent predictor of survival (HR= 2.68 95% CI: 1.5-4.4; p=0.0003) ![Figure][1] 10-year survival according to PPM/PLF Conclusion: In this catheterization-based study, patients with PLF and PPM have worse outcome when compared to those without these 2 conditions. [1]: pending:yes

Aortic Valve Prosthesis–Patient Mismatch and Long-Term Outcomes: 19-Year Single-Center Experience

The clinical effects of prosthesis-patient mismatch (PPM) after aortic valve replacement, with respect to morbidity and survival, remain controversial, particularly in high-risk patient subgroups. Patients undergoing aortic valve replacement from January 1992 to December 2010 were classified according to effective orifice area index into severe PPM (effective orifice area index<0.65 cm²/m²), moderate PPM (effective orifice area index 0.65 to 0.85 cm²/m²), and absent PPM (effective orifice area index>0.85 cm²/m²). Analyses examined major morbidity and total all-cause death. Prosthesis-patient mismatch was classified as severe (92 of 1,060; 8.7%), moderate (440 of 1,060; 41.5%), or absent (528 of 1,060; 49.8%). Moderate and severe PPM were unrelated to in-hospital morbidity or mortality. There were 440 deaths (41.5%) at 5.6 years median follow-up (interquartile range, 2.9 to 9.1). Trend toward poorer survival according to PPM group (χ2=5.46; p=0.07) was attenuated further with covariate adjustment. Sensitivity analyses demonstrated discrete mortality effects for moderate PPM in association with concomitant coronary artery bypass grafting, impaired left ventricular function, and older age (significant hazard ratios range, 1.05 to 1.57). Severe PPM also increased mortality risk in association with older age, concomitant coronary artery bypass grafting, and New York Heart Association Class III or IV (significant hazard ratios range, 1.06 to 2.65). Prosthesis-patient mismatch was not associated with mortality in covariate-adjusted models. However, a discrete mortality risk was attributable to moderate and severe PPM in patients of older age, or those with left ventricular dysfunction, New York Heart Association class III or IV, and concomitant coronary artery bypass grafting.

Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement

BackgroundThe influence of prosthesis-patient mismatch (PPM) on survival after aortic valve replacement (AVR) remains controversial. In this study, we sought to determine the effect of PPM on early (≤30 days) and late mortality (>30 days) after AVR or AVR combined with coronary artery bypass grafting (AVR with CABG).MethodsBetween January 1998 and March 2012, 2976 patients underwent AVR (n= 1718) or AVR with CABG (n=1258) at a single institution. PPM was defined as an indexed effective orifice area (EOAI) ≤0.85 cm2/m2 and patients were divided into two groups based on the existence of PPM. Cumulative probability values of survival were estimated with Kaplan-Meier method and compared between groups using Breslow test. Univariate and multivariate independent predictors of early mortality were identified using logistic regression. Cox proportional-hazard regression analysis was used to determine univariate and multivariate independent predictors of late mortality.ResultsEarly mortality was 6.7% in the PPM group vs 4.7% in the group with no PPM (p=0.013). Late mortality for the PPM group at 1, 5 and 10 years was 4%, 16% and 43%, respectively. Late mortality for the group with no PPM at 1, 5 and 10 years was 4%, 15% and 33% respectively. Independent predictors of early mortality included age, severely impaired left ventricular (LV) function, endocarditis, renal dysfunction, chronic obstructive pulmonary disease (COPD) and cardiopulmonary bypass (CPB) time. Multivariate independent predictors of late mortality included age, severely impaired LV function, diabetes, peripheral vascular disease (PVD), renal dysfunction, history of a cerebrovascular accident (CVA), CPB time and a history of previous cardiac surgery. PPM was not an independent predictor of early or late mortality.ConclusionPPM is not an independent predictor of both early and late mortality after AVR or AVR combined with CABG.

Patient-Prosthesis Mismatch in Patients With Aortic Stenosis Undergoing Isolated Aortic Valve Replacement Does Not Affect Survival

Data suggest that patient-prosthesis mismatch (PPM) adversely effects late survival after aortic valve replacement (AVR). This study examined the incidence and implications of PPM in patients undergoing isolated AVR. Prospectively collected data on patients undergoing isolated AVR for aortic stenosis between January 1, 1997 and December 31, 2007 were analyzed. The projected effective valve orifice area from in vivo data was indexed to body surface area (EOAi). PPM was defined as moderate for EOAi of < or = 0.85 cm(2)/m(2) and severe if < or = 0.6 cm(2)/m(2). The reference group comprised patients with EOAi > 0.85 cm(2)/m(2). The effect of PPM on postoperative survival was assessed by multivariate analysis. Of 801 patients, PPM was severe in 48 (6.0%), moderate in 462 (57.8%), and nonexistent in 291 (36.4%). Mismatch was associated with increasing age and female gender, thus resulting in an increase in the EuroSCORE (reference group, 4.9 +/- 2.6; moderate PPM, 5.8 +/- 2.4; and severe PPM, 6.1+/-2.1; p < 0.001). PPM did not significantly increase hospital mortality. Four deaths occurred in the reference group (1.4%), 12 in the moderate PPM (2.6%), and none in the severe PPM group (p = 0.311). The 5-year survival estimates were 83% in reference, 86% in moderate PPM, and 89% in severe PPM (p = 0.25). By multivariate analysis, PPM was not an independent risk factor for reduced in-hospital or late survival. Moderate PPM is common in patients undergoing AVR for aortic stenosis, but severe mismatch is rare. Patients with PPM have similar early and late postoperative survival rate.

Influence of prosthesis–patient mismatch on left ventricular remodelling in severe aortic insufficiency

The present study evaluates the impact of prosthesis-patient mismatch (PPM) on left ventricular remodelling following aortic valve replacement (AVR) for severe aortic insufficiency. In this study, 230 patients undergoing aortic valve surgery were divided into two groups depending on whether or not they exhibited PPM. Postoperative left ventricular (LV) dimensions and function were compared to the preoperative status. The incidence of PPM (EOAi <or=0.85 cm(2) m(-2)) was 22.2%. There was no significant difference in the reduction of mean end-diastolic LV diameter (LVEDD; p=0.31) or mean end-systolic LV diameter (LVESD; p=0.79) between the non-PPM and the PPM groups. The LVEDD was reduced in the non-PPM group from 66+/-9 to 55+/-9 mm postoperatively (p<0.001) while the LVEDD in the PPM group was reduced from 65+/-9 to 56+/-10mm (p<0.001). The LVESD was reduced in the non-PPM group from 49+/-10 to 40+/-10mm postoperatively (p<0.001) while the LVESD in the PPM group was reduced from 50+/-11 to 39+/-10mm (p<0.001). Patients with preoperative LV dysfunction (ejection fraction (EF) <50%) demonstrated a significant improvement in postoperative LVEF in both the non-PPM (36+/-8% to 44+/-12%, p<0.001) and PPM groups (33+/-7% to 46+/-11%, p=0.001) but no significant difference could be demonstrated in the rate of improvement between the two groups (p=0.23). Furthermore, no significant difference was found in survival between patients with PPM and those without (p=0.23). PPM did not influence left ventricular remodelling or survival following AVR for severe aortic insufficiency. The left ventricular remodelling process was initiated regardless of preoperative LVEF, and the impact of PPM seems to be of little importance.