Prosthesis-patient Mismatch In Patients Research Articles

Clinical and Echocardiographic Aspects of Patient-Prosthesis Mismatch in Patients With Prosthetic Aortic Valves

Clinical and Echocardiographic Aspects of Patient-Prosthesis Mismatch in Patients With Prosthetic Aortic Valves

Long term impact of measured and predicted prosthesis patient mismatch following transcatheter aortic valve replacement

Abstract Objectives To investigate the long-term clinical impact of prosthesis-patient mismatch (PPM) in patients undergoing transcatheter aortic valve implantation(TAVI). Background Both measured and predicted effective orifice area indexed to the body surface area (EOAi) have been suggested to define PPM in patients undergoing TAVI. The impact of PPM on clinical outcomes may accumulate with extended follow-up and vary according to the definition used. Methods Patients included in a prospective TAVI registry were stratified by the presence of moderate (0.65-0.85 cm2/m2 or 0.55-0.70 cm2/m2 if obese) or severe (≤0.65 cm2/m2 or ≤0.55 cm2/m2 if obese) PPM according to echocardiographically measured EOAi (measured PPM) prior to discharge, predicted EOAi based on published EOA reference values for each valve model and size (predicted PPMTHV), or predicted EOAi based on EOA reference derived from computed tomography measurements of aortic annulus dimension (predicted PPMCT). Results In an analysis of 2,463 patients, the incidence of measured PPM (moderate: 27.0%; severe: 8.7%) was higher than the incidence of predicted PPMTHV (moderate: 11.3%; severe: 1.2%) or predicted PPMCT (moderate: 12.0%; severe: 0.1%). During a median time to death of 843 days, mortality rates at 10 years were comparable in patients with versus without measured PPM or predicted PPMCT. In contrast, patients with moderate predicted PPMTHV had a lower risk of 10-year all-cause mortality compared with those without PPM (HR: 0.69; 95% CI: 0.52-0.90). Conclusions The use of predicted as compared to measured EOAi results in a lower estimate of PPM severity in TAVI ptients. We observed no increased risk of death in patients with PPM throughout 10-year of follow-up.Incidence of PPM after TAVIImpact of Measured an Predicted PPM

Influence of moderate prosthesis–patient mismatch on long-term outcomes in patients with severe aortic stenosis with paradoxically reduced gradients against the background of reduced stroke volume after aortic valve replacement with a biological prosthesis: retrospective comparative study

OBJECTIVE: Our aim was to evaluate the impact of moderate prosthesispatient mismatch on long-term results after aortic valve replacement in patients with severe aortic stenosis with paradoxically reduced gradients against the background of a reduced stroke volume of the left ventricle.
 MATERIALS AND METHODS: We analyzed data from 88 patients with symptomatic severe aortic stenosis meeting the criteria: paradoxically reduced gradients against the background of a reduced stroke volume of the left ventricle. Patients were divided into 2 groups: Group 1 (n=42, mean age 674 years) with paradoxically reduced gradients against the background of reduced stroke volume of the left ventricle, with a moderate patientprosthesis mismatch; Group 2 (n=46, mean age 686 years) with paradoxically reduced gradients against the background of reduced stroke volume of the left ventricle, without patientprosthesis discrepancy. All patients underwent transthoracic echocardiographic evaluation.
 RESULTS: The average follow-up period was 84 (quarterly interval 7598) months, during the follow-up period 35 (40%) deaths were registered. There were no significant differences in in-hospital mortality: 2 (4.7%) and 2 (4.3%), respectively (p=0.2). In the long-term follow-up period, there was a significant difference in survival and hospitalization rates for exacerbation of heart failure between patients with and without patientprosthesis mismatch: 46 and 71%, 37 and 72%, respectively (p0.001). In the long-term follow-up period, patients with patientprosthesis mismatch showed a trend towards slower regression of left ventricle mass and left atrial volume, as well as a slower recovery of global longitudinal deformation of the left ventricle and exercise tolerance compared with patients without patientprosthesis mismatch. There were no significant differences in the incidence of stroke (90% and 91%; p=0.7). According to the results of Cox regression, the left ventricular stroke volume index and the aortic valve effective orifice area index were independent predictors of lethal events and the risk of hospitalization for exacerbation of heart failure.
 CONCLUSION: Moderate patientprosthesis mismatch in patients with paradoxically reduced gradients associated with reduced left ventricular stroke volume is independently associated with increased mortality and increased hospitalization for exacerbations of heart failure.

Long-term outcomes of measured and predicted prosthesis-patient mismatch following transcatheter aortic valve replacement.

Both measured and predicted effective orifice area (EOA) indexed to the body surface area (EOAi) have been suggested to define prosthesis-patient mismatch (PPM) in patients undergoing transcatheter aortic valve replacement (TAVR). The impact of PPM on clinical outcomes may accumulate with extended follow-up and vary according to the definition used. We aimed to investigate the long-term clinical impact of PPM in patients undergoing TAVR. Patients in a prospective TAVR registry were stratified by the presence of moderate (0.65-0.85 or 0.55-0.70 cm2/m2 if obese) or severe (≤0.65 or ≤0.55 cm2/m2 if obese) PPM according to echocardiographically measured EOAi (measured PPM), predicted EOAi based on published EOA reference values for each valve model and size (predicted PPMTHV), or predicted EOAi based on EOA reference values derived from computed tomography measurements of aortic annulus dimensions (predicted PPMCT). In an analysis of 2,463 patients, the frequency of measured PPM (moderate: 27.0%; severe: 8.7%) was higher than the frequency of predicted PPMTHV (moderate: 11.3%; severe: 1.2%) or predicted PPMCT (moderate: 12.0%; severe: 0.1%). During a median follow-up of 429 days, 10-year mortality was comparable in patients with versus without measured PPM or predicted PPMCT. In contrast, patients with moderate predicted PPMTHV had a lower risk of 10-year all-cause mortality compared with those without PPM (adjusted hazard ratio: 0.73, 95% confidence interval: 0.55-0.96). The use of predicted versus measured EOAi results in a lower estimate of PPM severity. We observed no increased risk of death in patients with PPM over a median follow-up time of 429 days. gov: NCT01368250.

B-61 | Incidence of Patient Prosthesis Mismatch (PPM) After ViV-TAVI and ViV-TAVI With Bioprosthetic Valve Fracture (BVF)

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is an effective treatment for degenerated bioprosthetic valves in high-risk patients. Unfortunately, patient prosthesis mismatch (PPM) remains an issue. PPM is known to impact functional status, valve longevity, morbidity and mortality. Bioprosthetic valve fracturing (BVF) is a method by which operators fracture the bioprosthetic valve allowing for greater expansion of the new valve or implantation of a larger valve. We sought to determine the incidence of PPM in patients undergoing ViV-TAVI and the safety of BVF. Patients who underwent ViV-TAVI at our institution from 2015-2022 were selected and divided into two groups (with BVF and without BVF). BVF was performed at the discretion of the operator. PPM severity was assessed as insignificant, moderate or severe. Moderate PPM was defined as an indexed effective orifice area (iEOA) <0.85 cm2/m2 (if BMI<30 kg/m2) or <0.70 cm2/m2 (if BMI>30 kg/m2). Severe PPM was defined as an iEOA <0.65 cm2/m2 (if BMI<30 kg/m2) or <0.55 cm2/m2 (if BMI>30 kg/m2). Measurements were taken by TTE on post operative day 1. All-cause mortality was assessed at 30-days and at 1-year. A total of 78 patients underwent ViV-TAVI, of which 25 patients had suboptimal gradients and were successfully treated with BVF. The mean age was 76.71 years old. The overall mean iEOA post ViV-TAVI was 0.69 ± 0.20 cm2/m2. Severe PPM was present in 43.4% that underwent ViV-TAVI, while only in 16% of patients that underwent ViV-TAVI with BVF. 1 patient required a permanent pacemaker in the BVF group. Amongst patients who underwent ViV-TAVI, 96.2% of patients were living at 30-days and 90.6% of patients were living at 1-year. Amongst patients who underwent ViV-TAVI with BVF, 100% of patients were living at 30-days and 96% of patients were living at 1-year. PPM was present more often in ViV-TAVI patients compared to ViV-TAVI with BVF. Short term mortality appears to be similar between groups and complications rates are low.

Outcomes of Root Enlargement vs Root Replacement for Aortic Stenosis

BackgroundStentless aortic root replacement (ARR) and aortic root enlargement (ARE) are established strategies to avoid prosthesis-patient mismatch in patients with aortic stenosis (AS) and small annuli. We sought to compare outcomes of these 2 procedures. MethodsThis was an observational study using an institutional database of aortic valve replacements from 2010 to 2021. The study compared patients who underwent ARE vs ARR for AS. Those with endocarditis or aortic aneurysms were excluded. Postoperative outcomes were compared between groups. Kaplan-Meier survival estimation and multivariable Cox regression for survival were performed. Cumulative incidence functions were generated for all-cause readmissions. ResultsA total of 533 patients underwent either ARE or ARR for AS. Of these, 193 (36.2%) underwent ARE and 340 (63.8%) underwent ARR with a stentless xenograft. There were no significant differences in operative mortality, stroke, length of stay, or new-onset renal failure requiring dialysis. There were also no significant differences in aortic valve reintervention rates (3.1% vs 1.8%; P = .314). Patients in the ARR group had larger valves implanted, larger indexed effective orifice areas, lower rates of prosthesis-patient mismatch, and lower transprosthetic gradients (P < .001). Median follow-up was 5.02 (2.70-7.8) years. Kaplan-Meier survival estimates were comparable, and on multivariable Cox regression, ARR vs ARE was not significantly associated with an increased hazard of death (hazard ratio, 1.00; 95% CI, 0.69-1.45; P = .996). Cumulative incidence estimates for all-cause readmissions were also comparable between groups. ConclusionsARE and stentless xenograft ARR for AS were associated with comparable postoperative complications, aortic valve reinterventions, freedom from readmission, and 5-year survival.

Prosthesis-patient mismatch following transcatheter aortic valve replacement for degenerated transcatheter aortic valves: the TRANSIT-PPM international project.

BackgroundA severe prosthesis-patient mismatch (PPM) is associated with adverse outcomes following transcatheter aortic valve replacement (TAVR) for de novo aortic stenosis or a failed surgical bioprosthesis. The impact of severe PPM in patients undergoing TAV-in-TAVR is unknown.AimWe sought to investigate the incidence and 1-year outcomes of different grades of PPM in patients undergoing TAV-in-TAVR.Materials and methodsThe TRANSIT-PPM is an international registry, including cases of degenerated TAVR treated with a second TAVR. PPM severity, as well as in-hospital, 30-day, and 1-year outcomes were defined according to the Valve Academic Research Consortium-3 (VARC-3) criteria.ResultsAmong 28 centers, 155 patients were included. Severe PPM was found in 6.5% of patients, whereas moderate PPM was found in 14.2% of patients. The rate of severe PPM was higher in patients who underwent TAV-in-TAVR with a second supra-annular self-expanding (S-SE) TAVR (10%, p = 0.04). Specifically, the rate of severe PPM was significantly higher among cases of a SE TAVR implanted into a balloon-expandable (BE) device (19%, p = 0.003). At 1-year follow-up, the rate of all-cause mortality, and the rate of patients in the New York Heart Association (NYHA) class III/IV were significantly higher in the cohort of patients with severe PPM (p = 0.016 and p = 0.0001, respectively). Almost all the patients with a severe PPM after the first TAVR had a failed < 23 mm BE transcatheter heart valve (THV): the treatment with an S-SE resolved the severe PPM in the majority of the cases.ConclusionAfter TAV-in-TAVR, in a fifth of the cases, a moderate or severe PPM occurred. A severe PPM is associated with an increased 1-year all-cause mortality.Clinical trial registration[https://clinicaltrials.gov], identifier [NCT04500964].

Surgical aortic valve replacement provides better left ventricular mass regression than transcatheter aortic valve replacement in patients with small aortic annulus.

This study aimed to evaluate the incidence of patient-prosthesis mismatch (PPM) and degree of left ventricular (LV) mass regression after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) in patients with small aortic annulus (defined as annular diameter of ≤ 21mm). We retrospectively analyzed echocardiographic findings in total of 277 patients with aortic stenosis and small aortic annulus (63 underwent SAVR and 214 underwent TAVR) between October 2013 and March 2019. PPM was defined as an effective orifice area index (EOAI) ≤ 0.85 cm2/m2. LV mass regression was evaluated as percentage change in LV mass index (LVMI) from baseline to the 1-year follow-up. The median EOAI before discharge was slightly larger in the TAVR group than in the SAVR group (1.09 vs. 1.07 cm2/m2; P = 0.030). However, the incidence of PPM before discharge (9.4 vs. 12.7%; P = 0.438) and at the 1-year follow-up (11.7 vs. 11.1%; P = 0.901) was similar between groups. Mild or greater paravalvular leakage (PVL) after the procedure was more frequent in the TAVR group (11.7 vs. 0%; P = 0.002). Reduction in LVMI was significantly higher in the SAVR group (19.3 vs. 6.4%; P < 0.001). Multivariate analysis demonstrated that reduction in LVMI was positively associated with higher baseline transaortic pressure gradient (P < 0.001) and higher baseline LVMI (P < 0.001) and negatively associated with older age (P < 0.001) and mild or greater PVL (P < 0.001). SAVR provides better LV mass regression than TAVR with a comparable rate of PPM in patients with small aortic annulus.

Women and transcatheter aortic valve implantation: Also a mismatch could be tomorrow's best match

Key Points What the article teaches. Patient prosthesis mismatch (PPM) occurs in a third of women after transcatheter aortic valve replacement (TAVR), in association with small valve size and higher BMI, apparently without short‐term clinical consequences. How it will impact practice. Implementation strategies to minimize the incidence of PPM in patients at risk, that are mainly women, is important. What new research/study would help answer the question posed. Differential clinical impact of PPM on TAVR and surgical aortic valve replacement should be further investigated, as well as the hypothesis that TAVR might represent the best therapeutic option for women with severe aortic stenosis.

Accuracy of predicted effective orifice area in determining incidence of patient-prosthesis mismatch after transcatheter aortic valve replacement.

Patient-prosthesis mismatch (PPM) is associated with poor outcomes after aortic valve replacement. The aim of this study was to assess the accuracy of indexed effective orifice area (EOAi) charts in predicting PPM after transcatheter aortic valve replacement (TAVR). A retrospective review of 346 TAVR patients from January 2017 to November 2018 was performed. EOAi was predicted for patients based on published predictive tables using valve type, annulus diameter, and body surface area. Actual EOAi was calculated based on intraoperative transesophageal echocardiogram (TEE) measurements. PPM was defined by EOAi ≤ 0.85 cm2 /m2 . The accuracy of predicted PPM was assessed. Differences in clinical outcomes, including mean gradient, length of stay, mortality, complications, and change in Kansas City cardiomyopathy questionnaire score as an indicator of quality of life, were evaluated based on actual PPM. Of the 346 patients analyzed, 44 (12.7%) of patients had PPM on intraoperative TEE. Of the 182 patients who received Sapien 3 valves, 42 (23.1%) were predicted to have PPM while 25 (13.7%) had actual PPM. Of the 164 patients who received Evolut valves, 3 (1.8%) were predicted to have PPM while 19 (11.6%) had actual PPM. EOAi charts had poor sensitivity (40.0% for Sapien 3; 5.25% for Evolut) and positive predictive value (23.8% for Sapien 3; 33.3% for Evolut) for both valve types. Preoperative prediction of PPM in TAVR patients using tables of expected EOA demonstrates significant variation from actual PPM. The utility of EOAi charts to predict PPM in patients undergoing TAVR may be limited.

Prosthesis-patient mismatch after surgical aortic valve replacement in patients with aortic stenosis.

The issue of prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) has been a controversial topic. We sought to evaluate the long-term clinical impacts of PPM in patients undergoing SAVR in an updated, homogeneous cohort. Using the prospective institutional database, we identified 895 adult patients (median age 66, interquartile range 58-72; 45.6% women) who underwent isolated SAVR from January 2000 to March 2016. Those with pure aortic insufficiency and concomitant other cardiac operations were excluded from this study cohort. The presence of a significant PPM was defined as an indexed effective orifice area 0.85 cm2/m2 or less. The outcome of interest was all-cause deaths. Propensity score matching was performed for adjusting bias. Significant PPM was present in 247 patients (27.6%). During the follow-up period (mean 71.2 ± 51.04 months), 134 patients (15%) died. Survival rates at 10 and 15 years were 78.3% vs 83.8% and 71.3% vs 57.6% in the PPM and non-PPM groups (P = 0.972). Risk factor analysis indicated that developing PPM was not associated with a risk of death. After propensity score matching (1:1), developing PPM was not a risk factor for long-term death as well (P = 0.584). Significant PPM was common after SAVR in patients with aortic stenosis. However, there was no significant difference in survival rate between those with and without PPM.

Patient-prosthesis mismatch in patients with mechanic aortic valve replacement: Which method is better: In vitro or in vivo measurement?

Patient-prosthesis mismatch is usually accepted to be associated with poor outcomes in patients with aortic valve replacement (AVR). This study aims to evaluate prevalence, sensitivity and specificity of mismatch measured with in vivo and in vitro methods, look for a relationship between mismatch and obesity, and investigate the effect of mismatch on left ventricle mass index (LVMI) regression and mortality. A total of 72 consecutive patients who underwent mechanical AVR between December 2011 and May 2013, were prospectively evaluated. EOA was measured with echocardiography in all patients on the 6th postoperative month and an Indexed Effective Orifice Area (EOA) ≤0.85cm2/m2 was accepted as mismatch with the in vivo measurement method. For the in vitro measurement method, charts provided by the valve manufacturers were used for EOA prediction. LVMI was also evaluated on the 6th and 12th postoperative months. Postoperative follow-up is 100% complete with 68.5±14.4 months. In vivo and in vitro mismatch prevalences were 43.5% and 25.0% with slight concordance (kappa=0.172). Sensitivity of in vitro measurements was poor (35.7%), but specificity was 80.5%. LVMI regressions were significant with both mismatch methods (p0.05 in both). In vitro EOA measurements have a poor sensitivity to predict mismatch preoperatively. Left ventricular mass regressions were significant in all groups with no difference in early and late mortality.

Impact of Left Ventricular Function on Patient-Prosthesis Mismatch Post Transcatheter Aortic Valve Replacement

Background There is limited data on whether development of patient-prosthesis mismatch (PPM) depends on left ventricular function at the time of TAVR, especially with newer generation transcatheter heart valves (THVs). Our study sought to investigate the predictive value of left ventricular ejection fraction (LVEF) on development of PPM, as well as long-term clinical outcomes of PPM in patients with preserved, mid-range, and reduced ejection fraction. Methods This is a retrospective cohort study of patients with preserved (EF > 50%), mid-range (EF 40-50%), and reduced (EF Results A total of 991 patients underwent TAVR. There were 423 (43%) females with median age of 85, STS score of 4.9 and LVEF of 60%. There were 657 (66%) patients received Sapien 3 THVs and 60 (6%) received Evolut R/Pro THVs. A total of 274 patients (28%) developed PPM. There were 58 (21%) patients with reduced EF, 38 (14%) patients with mid-range EF, and 178 (65%) with preserved EF who developed PPM (p=0.92). Outcomes of these patients are presented in Table 1. Reduced EF was significantly associated with lower 5-year mortality (Figure 1). Conclusions Our study suggests that left ventricular function at the time of TAVR is not a predictor for development of PPM. LVEF does not appear to have impact on short-term clinical outcomes of PPM; however, it does appear to associate with decreased long-term survival. Larger randomized controlled trials are needed to further investigate the impact of LVEF.

Predicting patient–prosthesis mismatch by aortic root evaluation before aortic valve replacement

ObjectiveThis study aimed to assess the predictors of patient–prosthesis mismatch (PPM) after surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) using preoperative computed tomography. MethodsWe enrolled 323 patients undergoing SAVR (n = 85) or TAVR (n = 238) for aortic stenosis. The end point was any degree of PPM (effective orifice area index <0.85 cm2/m2). We assessed the predictors of PPM after SAVR or TAVR and compared the incidence of PPM between both arms. Furthermore, we compared the hemodynamic performance using the propensity score matching. ResultsThe occurrence of PPM was significantly higher in the SAVR arm (24.7% vs 7.1%; P < .001). A small sinotubular junction was an independent predictor of PPM in the SAVR arm (odds ratio, 0.79; 95% confidence interval, 0.65-0.96; P = .015), but not a significant predictor in the TAVR arm. In patients with a small sinotubular junction, the prevalence of PPM in the SAVR arm was higher (57.9% vs 2.9%; P < .001). Furthermore, among the propensity score-matched patients, the incidence of PPM in the SAVR arm was higher than that in the TAVR arm (26.3% vs 12.5%; P = .031). ConclusionsIn patients with a small sinotubular junction detected by preoperative computed tomography assessment, the incidence of PPM in patients undergoing SAVR was higher.

Intentional Fracture of Bioprosthetic Valve Frames in Patients Undergoing Valve-in-Valve Transcatheter Pulmonary Valve Replacement.

Percutaneous transcatheter pulmonary valve replacement (TPVR) has good clinical and hemodynamic outcomes in treating dysfunctional bioprosthetic valves (BPV) in the pulmonary position. Valve-in-valve therapy can further decrease the inner diameter (ID), potentially resulting in patient-prosthesis mismatch in patients with smaller BPVs. To evaluate feasibility and outcomes of intentional BPV fracture to enlarge the pulmonary valve orifice with TPVR, 37 patients from 13 centers who underwent TPVR with intended BPV fracture were evaluated. A control cohort (n=70) who underwent valve-in-valve TPVR without attempted fracture was evaluated. BPV was successfully fractured in 28 patients and stretched in 5 while fracture was unsuccessful in 4. A Melody valve was implanted in 25 patients with fractured/stretched frame and a Sapien (XT 3) valve in 8. Among patients whose BPV was fractured/stretched, the final ID was a median of 2 mm larger (0-6.5 mm) than the valve's true ID. The narrowest diameter after TPVR in controls was a median of 2 mm smaller ( P<0.001) than true ID. Right ventricular outflow tract gradient decreased from median 40 to 8 mm Hg in the fracture group. Cases with fracture/stretching were matched 1:1 (weight, true ID) to controls. Post-TPVR peak gradient was lower but not significant (8.3±5.2 versus 11.8±9.2 mm Hg; P=0.070). There were no fracture-related adverse events. Preliminary experience shows intentional fracture of BPV frame can be useful for achieving larger ID and better hemodynamics after valve-in-valve TPVR.

Does patient-prosthesis mismatch have a negative impact on outcomes following mitral valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patient-prosthesis mismatch (PPM) has a negative impact on patients undergoing mitral valve replacement in terms of postoperative mortality, incidence of postoperative pulmonary hypertension (PH) and higher transmitral gradients. Altogether 103 papers were found using the reported search, 18 of which represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Overall, 8 studies with a total of 4812 patients reported that PPM has a significantly negative impact on long-term mortality, whereas 5 studies with a total of 1558 patients reported no effect on mortality. One study with a total of 2440 patients reported preoperative PH as the risk factor for increased mortality in the presence of moderate or severe PPM. Three studies evaluated the effect of PPM on postoperative PH and reported that PPM was associated with significantly increased postoperative PH. The majority of the studies reported that PPM was associated with higher peak or mean transmitral gradient and systolic pulmonary artery pressure. The results presented in these studies suggest that PPM in patients undergoing mitral valve replacement was associated with increased postoperative mean and peak transmitral gradient and higher postoperative systolic pulmonary artery pressure. PPM may be associated with increased long-term mortality. Severe PPM was directly associated with increased long-term mortality when compared with moderate or no PPM. Evidence suggests that PPM is associated with increased incidence of postoperative PH.

CT-Defined Prosthesis–Patient Mismatch Downgrades Frequency and Severity, and Demonstrates No Association With Adverse Outcomes After Transcatheter Aortic Valve Replacement

ObjectivesThis study sought to determine if indexed effective orifice area (EOAi), using left ventricular outflow tract measured from computed tomography (EOAiCT), reclassified prosthesis–patient mismatch (PPM) compared with conventional echocardiogram-defined measurements (EOAiTTE). BackgroundPPM does not predict mortality following transcatheter aortic valve replacement (TAVR). However, it is unknown if the EOAiCT of the left ventricular outflow tract improves risk stratification. MethodsA total of 765 TAVR patients from the PARTNER II (Placement of Aortic Transcatheter Valves II) trial S3i cohort were evaluated. EOAi was calculated using the continuity equation, and the left ventricular outflow tract area was derived from baseline computed tomography. Traditional echocardiographic categories defined PPM: absent (>0.85 cm2/m2), moderate (≥0.65 and ≤0.85 cm2/m2), or severe (≤0.65 cm2/m2). Correlation of EOAiCT and EOAiTTE to 1-year outcomes was performed. ResultsThe incidence of PPM was 24% with EOACT compared with 45% with EOAiTTE. Only 6% of PPM was graded severe by EOAiCT compared with 9% by EOAiTTE. EOAiTTE, but not EOAiCT, defined PPM showed association with reduced left ventricular mass regression (p = 0.03 vs. p = 0.52). There was no association between PPM and death or rehospitalization at 1 year with either modality. EOACT was associated with minor stroke at 1 year (log-rank p = 0.04), and EOAiTTE with stroke/transient ischemic attack (log-rank p = 0.030). Furthermore, when subjects with mild or greater paravalvular regurgitation were excluded, the presence of PPM did not show association with any outcome. ConclusionsEOAiCT downgrades frequency and severity of PPM in patients after TAVR, and was not associated with mortality 1 year after TAVR. EOAiTTE, but not EOAiCT, was associated with less left ventricular mass regression.

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots.

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Patient-prosthesis mismatch in patients treated with transcatheter aortic valve implantation - predictors, incidence and impact on clinical efficacy. A preliminary study.

IntroductionPatient-prosthesis mismatch (PPM) is relatively frequent after surgical aortic valve replacement (SAVR) and negatively impacts prognosis.AimWe sought to determine the frequency and clinical effects of PPM after transcatheter aortic valve implantation (TAVI).Material and methodsOverall, 238 patients who underwent TAVI were screened. Moderate PPM was defined as indexed effective orifice area (EOAi) between 0.65 and 0.85 cm2/m2, and severe PPM as < 0.65 cm2/m2. All-cause mortality and the Valve Academic Research Consortium 2 (VARC-2) defined composite of clinical efficacy at 1 year were the primary endpoints.ResultsFinally, 201 patients were included (mean age: 79.6 ±7.4 years, 52% females). The femoral artery served as the delivery route in 79% and most of the prostheses were self-expanding (68%). Any PPM was present in 48 (24%) subjects, and only 7 (3.5%) had severe PPM. Body surface area (BSA) independently predicted any PPM (OR = 16.9, p < 0.001) whereas post-dilation tended to protect against PPM (OR = 0.46, p = 0.09). All-cause mortality was similar in patients with moderate or severe PPM as compared to those with no PPM (14.6% vs. 14.3% vs. 13.1%, respectively, log-rank p = 0.98). Neither moderate (OR = 1.6, 95% CI: 0.8–3.2, p = 0.16) nor severe PPM (OR = 1.67, 95% CI: 0.36–7.7, p = 0.51) had a significant impact on composite endpoint, or its elements, with the exception of transvalvular pressure gradient > 20 mm Hg.ConclusionsSevere PPM after TAVI is rare, can be predicted by larger BSA and does not seem to affect mid-term mortality or composite clinical outcome. Larger studies are needed to find different independent predictors of PPM and elucidate its impact in terms of device durability and long-term clinical efficacy.

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.