Prosthesis-Patient Mismatch: The Complex Interaction between Cardiac Output and Prosthetic Valve Effective Orifice Area

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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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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Validation of methods for effective orifice area measurement of prosthetic valves by two-dimensional and Doppler echocardiography following transcatheter self-expanding aortic valve implantation

10.21203/rs.2.21550/v1 ◽

2020 ◽

Author(s):

Minghu Xiao ◽

Yongjian Wu ◽

Jingjin Wang ◽

Guangyuan Song ◽

Jiande Wang ◽

...

Keyword(s):

Aortic Valve ◽

Prosthetic Valve ◽

Interobserver Reliability ◽

Leading Edge ◽

Left Ventricular ◽

Area Measurement ◽

Effective Orifice Area ◽

Orifice Area ◽

Aortic Valve Implantation ◽

Valve Implantation

Abstract Background: The aim was to compare two echocardiographic methods for prosthetic valve effective orifice area (EOA) measurement following transcatheter self-expanding aortic valve implantation. Methods: EOA was calculated according to the continuity equation. Two methods were constructed. In Method #1, the left ventricular outflow tract diameter (LVOTd 1 ) was measured at the entry of the prosthesis (from trailing to leading edge); in Method #2, the LVOTd 2 was measured proximal to the prosthetic valve leaflets (from trailing to leading edge). VTI LVOT was recorded by pulse doppler (PW) from apical windows. The region of the PW sampling should match that of the LVOTd measurement with precise localization. Results: A total of 113 consecutive patients were included in the study. All patients were followed up at one year. The mean transvalvular pressure gradient correlated better with the indexed EOA 1 (EOAI 1 ) (r=-0.701, p<0.0001) than EOAI 2 (r=-0.645, p<0.0001). Intra-observer reliability of EOA 1 and was EOA 2 was excellent (ICCs ranging from: EOA 1 : 0.923 to 0.984, and EOA 2 : 0.898 to 0.979, respectively). Interobserver reliability of EOA 1 and was EOA 2 was good (ICCs ranging from: EOA 1 : 0.742 to 0.948, and EOA 2 : 0.589 to 0.901, respectively). Conclusions: For transcatheter self-expanding valve EOA measurement, LVOTd should be measured in the entry of the prosthesis stent (from trailing to leading edge), and VTI LVOT should be measured when the PW sample is located in the entry of the prosthesis stent.

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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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Validity of identifying patient-prosthesis mismatch from the indexed effective orifice area

Journal of Artificial Organs ◽

10.1007/s10047-008-0424-5 ◽

2008 ◽

Vol 11 (3) ◽

pp. 163-164 ◽

Cited By ~ 1

Author(s):

Yoshimasa Sakamoto ◽

Kazuhiro Hashimoto ◽

Hiroshi Okuyama ◽

Shinichi Ishii ◽

Noriyasu Kawada ◽

...

Keyword(s):

Effective Orifice Area ◽

Orifice Area ◽

Patient Prosthesis Mismatch

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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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Effective systolic orifice area of the aortic valve: implications for Doppler echocardiographic cardiac output determinations

Acta Anaesthesiologica Scandinavica ◽

10.1111/j.1399-6576.2005.00763.x ◽

2005 ◽

Vol 49 (8) ◽

pp. 1135-1141 ◽

Cited By ~ 2

Author(s):

C. Schmidt ◽

G. Theilmeier ◽

H. Van Aken ◽

C. Flottmann ◽

S. P. Wirtz ◽

...

Keyword(s):

Cardiac Output ◽

Aortic Valve ◽

Orifice Area

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Hemodynamic influence of design parameters of novel venous valve prostheses

Current Directions in Biomedical Engineering ◽

10.1515/cdbme-2018-0037 ◽

2018 ◽

Vol 4 (1) ◽

pp. 149-151

Author(s):

Michael Stiehm ◽

Stefanie Kohse ◽

Kerstin Schümann ◽

Sebastian Kaule ◽

Stefan Siewert ◽

...

Keyword(s):

High Sensitivity ◽

Lower Limbs ◽

Hydrodynamic Performance ◽

Design Parameters ◽

Effective Orifice Area ◽

Valve Prosthesis ◽

Venous Valve ◽

Orifice Area ◽

Valve Prostheses

AbstractVenous ulcers of the lower limbs are one clinical manifestation of chronic venous insufficiency. Currently, there is no venous valve prosthesis available. This study presents novel venous valve prostheses made of threedimensional electrospun fibrous nonwoven leaflets. The aim of this study was to prove the feasibility of the manufacturing process as well as to investigate design features of the venous valve prostheses from a hemodynamic point of view. An adapted pulse duplicator system (ViVitrolabs, Victoria, BC, CA) was used for characterization of the hydrodynamic performance. For eight different venous valve prototypes flow rate, effective orifice area and regurgitation fraction was investigated in vitro. In particular, tricusp valve designs showed an up to 40% higher effective orifice area as well as 15% higher maximum flowrate compared to bicusp valve designs. However, the regurgitation fraction of the bicusp valve designs is up to 86% lower compared to tricusp valve. Additionally, the hemodynamic performance of the tricuspid valves showed a high sensitivity regarding the leaflet length. Bicuspid valves are less sensitive to changes of design parameters, more sufficient and therefore highly reliable.

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