Reply: Relating the indexed effective orifice area and mean transprosthesis gradient to define patient–prosthesis mismatch: Are we sure a relationship exists?

Large studies demonstrated that moderate or severe patient-prosthesis mismatch (PPM) occurs in 44.2% to 65% of patients undergoing aortic valve replacement. If there is general agreement that patients with PPM have worse outcome than patients without, it is difficult to understand how to prevent this dangerous complication. The formula used to calculate the effective orifice area (EOA) of an implanted aortic prosthesis has many weak points that produce inconsistent results using the same prosthetic valve (type and size). The observed EOA (3 to 6 months postoperatively) of a #23 biological prosthesis can range from 0.9 to 3.5 cm², making PPM prevention impossible using projected EOA, where only the mean value is reported (1.83 cm² for the same #23 biological prosthesis). An EACTS-STS-AATS Valve Labelling Task Force has been established to suggest the manufacturers to present essential information on valvular prosthesis characteristics in standardized Valve Charts. For valves used in the aortic position, Valve Charts should include a standardized PPM chart to assess the probability of PPM after implantation. This will not solve completely the conundrum of prevention, but most likely it will be a step ahead.

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Bioprosthetic Valve Fracture During Valve-in-valve TAVR: Bench to Bedside

Interventional Cardiology Review ◽

10.15420/icr.2017:29:1 ◽

2017 ◽

Vol 13 (01) ◽

pp. 20 ◽

Cited By ~ 24

Author(s):

John T Saxon ◽

Keith B Allen ◽

David J Cohen ◽

Adnan K Chhatriwalla ◽

◽

...

Keyword(s):

Effective Means ◽

Evidence Base ◽

Bioprosthetic Valve ◽

Current Evidence ◽

Effective Orifice Area ◽

Orifice Area ◽

Transcatheter Heart Valve ◽

Current Evidence Base ◽

Patient Prosthesis Mismatch ◽

Valve In Valve

Valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) has been established as a safe and effective means of treating failed surgical bioprosthetic valves (BPVs) in patients at high risk for complications related to reoperation. Patients who undergo VIV TAVR are at risk of patient—prosthesis mismatch, as the transcatheter heart valve (THV) is implanted within the ring of the existing BPV, limiting full expansion and reducing the maximum achievable effective orifice area of the THV. Importantly, patient—prosthesis mismatch and high residual transvalvular gradients are associated with reduced survival following VIV TAVR. Bioprosthetic valve fracture (BVF) is as a novel technique to address this problem. During BPV, a non-compliant valvuloplasty balloon is positioned within the BPV frame, and a high-pressure balloon inflation is performed to fracture the surgical sewing ring of the BPV. This allows for further expansion of the BPV as well as the implanted THV, thus increasing the maximum effective orifice area that can be achieved after VIV TAVR. This review focuses on the current evidence base for BVF to facilitate VIV TAVR, including initial bench testing, procedural technique, clinical experience and future directions.

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Reconsideration of Patient-Prosthesis Mismatch Definition From the Valve Indexed Effective Orifice Area

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2010.03.011 ◽

2010 ◽

Vol 89 (6) ◽

pp. 1951-1955 ◽

Cited By ~ 6

Author(s):

Yoshimasa Sakamoto ◽

Michio Yoshitake ◽

Hirokuni Naganuma ◽

Noriyasu Kawada ◽

Katsushi Kinouchi ◽

...

Keyword(s):

Effective Orifice Area ◽

Orifice Area ◽

Patient Prosthesis Mismatch

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Incidence and predictors of mismatch after mechanical mitral valve replacement

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492319869560 ◽

2019 ◽

Vol 27 (7) ◽

pp. 535-541

Author(s):

Ashraf AH El Midany ◽

Ezzeldin A Mostafa ◽

Tamer Hikal ◽

Mostafa G Elbarbary ◽

Ayman Doghish ◽

...

Keyword(s):

Risk Factors ◽

Atrial Fibrillation ◽

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Left Ventricular ◽

Effective Orifice Area ◽

Orifice Area ◽

Patient Prosthesis Mismatch

Background Patient-prosthesis mismatch after mitral valve replacement has an unfavorable postoperative hemodynamic outcome, which underlines the importance of identifying and preventing prosthesis- and patient-related risk factors. This study was conducted to determine the incidence and identify possible predictors of patient-prosthesis mismatch. Methods A prospective study was conducted on 715 patients with a mean age of 42 ± 11 years who underwent mechanical mitral valve replacement between 2013 and 2017. The effective orifice area of the prostheses was estimated by the continuity equation, and a mismatch was defined as an effective orifice area index ≤1.2 cm2·m−2. The mean clinical and echocardiographic follow-up was 26.74 ± 11.58 months. Multivariate regression analysis was performed to identify predictors of patient-prosthesis mismatch. Results Patient-prosthesis mismatch was detected in 382 (53.4%) patients. A small mechanical prosthesis (<27 mm) was inserted in 54.3%. Mortality during follow-up was 9% (65 patients). Patient-prosthesis mismatch was identified in patients with preoperative rheumatic mitral valve pathology, associated tricuspid regurgitation, higher New York Heart Association class, preoperative atrial fibrillation, mitral stenosis, and small preoperative left ventricular dimensions. Multivariate analysis identified mitral stenosis, preoperative atrial fibrillation, and small postoperative left ventricular end-diastolic dimension as risk factors for patient-prosthesis mismatch. Conclusion Patient-prosthesis mismatch is a common sequela after mechanical mitral valve replacement. Identification of predictors of patient-prosthesis mismatch can help so that a preoperative strategy can be implemented to avoid its occurrence.

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Patient-prosthesis mismatch following aortic valve replacement

Heart ◽

10.1136/heartjnl-2018-313515 ◽

2019 ◽

Vol 105 (Suppl 2) ◽

pp. s28-s33 ◽

Cited By ~ 12

Author(s):

Rajdeep Bilkhu ◽

Marjan Jahangiri ◽

Catherine M Otto

Keyword(s):

Renal Failure ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Prosthetic Valve ◽

Left Ventricular ◽

Effective Orifice Area ◽

Orifice Area ◽

Cardiac Symptoms ◽

Patient Prosthesis Mismatch

Patient-prosthesis mismatch (PPM) occurs when an implanted prosthetic valve is too small for the patient; severe PPM is defined as an indexed effective orifice area (iEOA) <0.65 cm2/m2 following aortic valve replacement (AVR). This review examines articles from the past 10 years addressing the prevalence, outcomes and options for prevention and treatment of PPM after AVR. Prevalence of PPM ranges from 8% to almost 80% in individual studies. PPM is thought to have an impact on mortality, mainly in patients with severe PPM, although severe PPM accounts for only 10–15% of cases. Outcomes of patients with moderate PPM are not significantly different to those without PPM. PPM is associated with higher rates of perioperative stroke and renal failure and lack of left ventricular mass regression. Predictors include female sex, older age, hypertension, diabetes, renal failure and higher surgical risk score. PPM may be a marker of comorbidity rather than a risk factor for adverse outcomes. PPM should be suspected in patients with persistent cardiac symptoms after AVR when there is high prosthetic valve velocity or gradient and a small calculated effective orifice area. After exclusion of other causes of increased transvalvular gradient, re-intervention may be considered if symptoms persist and are unresponsive to medical therapy. However, this decision needs to consider the available options to relieve PPM and whether expected benefits justify the risk of intervention. The only effective intervention is redo surgery with implantation of a larger valve and/or annular enlargement. Therefore, focus needs to be on prevention.

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

Journal of Cardiac Surgery ◽

10.1111/jocs.15148 ◽

2020 ◽

Vol 36 (1) ◽

pp. 191-196

Author(s):

Michael A. Catalano ◽

Bruce Rutkin ◽

Elana Koss ◽

Greg Maurer ◽

Jacinda Berg ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Effective Orifice Area ◽

Orifice Area ◽

Transcatheter Aortic Valve ◽

Patient Prosthesis Mismatch

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The Usefulness of [18F]F-Fluorodeoxyglucose and [18F]F-Sodium Fluoride Positron Emission Tomography Imaging in the Assessment of Early-Stage Aortic Valve Degeneration after Transcatheter Aortic Valve Implantation (TAVI)—Protocol Description and Preliminary Results

Journal of Clinical Medicine ◽

10.3390/jcm10030431 ◽

2021 ◽

Vol 10 (3) ◽

pp. 431

Author(s):

Danuta Sorysz ◽

Rafał Januszek ◽

Anna Sowa-Staszczak ◽

Anna Grochowska ◽

Marta Opalińska ◽

...

Keyword(s):

Aortic Valve ◽

Emission Tomography ◽

Effective Orifice Area ◽

Orifice Area ◽

Transcatheter Aortic Valve ◽

Positron Emission ◽

Pet Ct ◽

Transvalvular Gradient ◽

Valve Implantation

Transcatheter aortic valve implantation (TAVI) is now a well-established treatment for severe aortic stenosis. As the number of procedures and indications increase, the age of patients decreases. However, their durability and factors accelerating the process of degeneration are not well-known. The aim of the study was to verify the possibility of using [18F]F-sodium fluoride ([18F]F-NaF) and [18F]F-fluorodeoxyglucose ([18F]F-FDG) positron emission tomography/computed tomography (PET/CT) in assessing the intensity of TAVI valve degenerative processes. In 73 TAVI patients, transthoracic echocardiography (TTE) at initial (before TAVI), baseline (after TAVI), and during follow-up, as well as transesophageal echocardiography (TEE) and PET/CT, were performed using [18F]F-NaF and [18F]F-FDG at the six-month follow-up (FU) visit as a part of a two-year FU period. The morphology of TAVI valve leaflets were assessed in TEE, transvalvular gradients and effective orifice area (EOA) in TTE. Calcium scores and PET tracer activity were counted. We assessed the relationship between [18F]F-NaF and [18F]F-FDG PET/CT uptake at the 6 = month FU with selected indices e.g.,: transvalvular gradient, valve type, EOA and insufficiency grade at following time points after the TAVI procedure. We present the preliminary PET/CT ([18F]F-NaF, [18F]F-FDG) results at the six-month follow-up period as are part of an ongoing study, which will last two years FU. We enrolled 73 TAVI patients with the mean age of 82.49 ± 7.11 years. A significant decrease in transvalvular gradient and increase of effective orifice area and left ventricle ejection fraction were observed. At six months, FU valve thrombosis was diagnosed in four patients, while 7.6% of patients refused planned controls due to the COVID-19 pandemic. We noticed significant correlations between valve types, EOA and transaortic valve gradients, as well as [18F]F-NaF and [18F]F-FDG uptake in PET/CT. PET/CT imaging with the use of [18F]F-FDG and [18F]F-NaF is intended to be feasible, and it practically allows the standardized uptake value (SUV) to differentiate the area containing the TAVI leaflets from the SUV directly adjacent to the ring calcifications and the calcified native leaflets. This could become the seed for future detection and evaluation capabilities regarding the progression of even early degenerative lesions to the TAVI valve, expressed as local leaflet inflammation and microcalcifications.

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Abstract 17870: Hemodynamic Performance of Transcatheter Prosthetic Valve is Superior to that of Surgical Prosthetic Valve for Aortic Valve Stenosis with Small Aortic Root

Circulation ◽

10.1161/circ.130.suppl_2.17870 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Koichi Maeda ◽

Toru Kuratani ◽

Kei Torikai ◽

Isamu Mizote ◽

Yasuhiro Ichibori ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Predictive Factor ◽

Aortic Root ◽

Prosthetic Valve ◽

The Other ◽

Effective Orifice Area ◽

Orifice Area ◽

Small Aortic Root ◽

Hemodynamic Performance

Introduction: Surgical aortic valve replacement (SAVR) in a small aortic root is still challenging with regard to the surgical technique and prosthesis size selection, which often causes patient-prosthesis mismatch (PPM). On the other hand, because a prosthetic valve of transcatheter aortic valve replacement (TAVR) is tightly implanted inside a native valve, larger effective orifice area (EOA) may be gained. The aim of this study is to prove that hemodynamic performance after TAVR is superior to that after SAVR. Methods: 160 patients, who underwent SAVR (n=36; age 75.1±5.6 years) and TAVR (n=124; age 82.4±6.8 years) for aortic valve stenosis, were enrolled. Preoperative ECG-gated multi-slice CT (MSCT) and echocardiography immediately before a discharge were performed in all patients. PPM was defined as the effective orifice area index ≤0.85cm2/m2 and we compared and examined hemodynamic performance after TAVR and SAVR. Results: Although the mean body size was significantly smaller (p<.05) in TAVR than that in SAVR (1.44±0.15 vs 1.51±0.20 m2), there were no significant differences in the diameters of annulus (23.2±1.6 vs 23.3±2.8 mm), valsalva sinus (29.8±2.6 vs 29.9±4.4 mm), and ST junction (25.2±2.8 vs 24.8±3.5 mm) on preoperative MSCT findings. Postoperative echocardiography revealed significantly less Vmax (2.2±0.4 vs 2.5±0.5 m/s, p<.0001), less mean pressure gradient (10.1±3.6 vs 14.5±5.0 mmHg, p<.0001), and larger EOA (1.62±0.29 vs 1.45±0.36 cm2, p<.005) in TAVR compared to SAVR, respectively. Consequently, PPM was more frequently in SAVR compared to TAVR (33.3 vs 8.9%; p<.0007). In multivariate analysis in SAVR identified small ST junction with only predictive factor of PPM (odds ratio [OR], 2.08; 95% CI, 1.23-4.36; p<.005; area under the receiver-operating characteristic curve [AUC], 0.84). On the other hand, regarding TAVR, large BSA was only predictive factor of PPM (p<.05). Conclusions: The hemodynamic performance of transcatheter prosthetic valve is superior to that of surgical prosthetic valve in a patient with small aortic root, in particular, small ST junction. TAVR should be considered in patients with anticipated PPM if the surgical risk is similar to TAVR.

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Comparison of the hemodynamic parameters of transaortic blood flow in patients with aortic stenosis depending on the bicuspid or tricuspid valve structure

Medical Visualization ◽

10.24835/1607-0763-2020-4-74-80 ◽

2020 ◽

Vol 24 (4) ◽

pp. 74-80

Author(s):

V. V. Bazylev ◽

R. M. Babukov ◽

F. L. Bartosh ◽

A. V. Gorshkova

Keyword(s):

Blood Flow ◽

Aortic Valve ◽

Aortic Stenosis ◽

Effective Area ◽

Effective Orifice Area ◽

Hemodynamic Parameters ◽

Structure Comparison ◽

Area Index ◽

Orifice Area ◽

Echocardiographic Study

Purpose: comparison of hemodynamic parameters of transaortic blood flow in patients with aortic stenosis depending on the bivalve or tricuspid structure of the aortic valve.Materials and methods. A study of 180 patients with isolated aortic valve stenosis (AC) with two – and threeleaf structure was conducted. Patients were ranked into 3 comparison subgroups by the area of the effective AC opening from 4 to 1.5 cm2; 1.5 to 1 cm2 and less than 1 cm2. An echocardiographic study was performed with the calculation of all the necessary parameters for the study.Results. The comparison subgroups were comparable in terms of effective orifice area (AVA), effective orifice area index (IAVA), body mass index (BMI), LV UO index, and LV FV (p > 0.05). However, the indicators Vmax, Gmean, and AT in patients with a bivalve AK structure in all comparison subgroups were significantly higher than in patients with a tricuspid structure. Comparison subgroup with AVA from 4 to 1.5 cm2: Vmax 2.8 ± 9 m/s and 2.5 ± 6 m/s p = 0.02. Gmean 18.6 ± 7.2 mm Hg and 15 ± 6 mm Hg p = 0.03, AT 82 ± 12 ms and 70 ± 10 ms p = 0.002. Comparison subgroup with AVA from 1.5 to 1 cm2: Vmax 3.7 ± 0.8 m/s and 3.5 ± 0.6 m/s p = 0.02. Average transaortic gradient 37 ± 10 mm Hg and 29 ± 5 mm Hg p = 0.04, AT 103 ± 11 ms and 94 ± 10 ms p = 0.02. Comparison subgroup with an effective area of less than 1 cm2: Vmax 5.7 ± 1.2 m/s and 4.7 ± 0.7 m/s p = 0.001, Gmean 54 ± 15 and 43 ± 11 mm Hg p < 0.001, AT 127 ± 20 ms and 112 ± 10 ms p = 0.002.Conclusion. Echocardiographic indicators of Vmax and Gmean in patients with bivalve AC structure have higher values than in patients with tricuspid AC structure with a comparable opening area.

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