Severe Patient-Prosthesis Mismatch: Compelling Entity or an Epiphenomenon of Low Flow?

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.

Download Full-text

Perceval or Trifecta to Prevent Patient–Prosthesis Mismatch

Journal of Clinical Medicine ◽

10.3390/jcm9092964 ◽

2020 ◽

Vol 9 (9) ◽

pp. 2964

Author(s):

Daniel Hernandez-Vaquero ◽

Carlota Vigil-Escalera ◽

Yvan Persia ◽

Carlos Morales ◽

Isaac Pascual ◽

...

Keyword(s):

Logistic Regression ◽

Aortic Valve ◽

Logistic Regression Model ◽

Multinomial Logistic Regression ◽

The Other ◽

Multinomial Logistic Regression Model ◽

Patient Prosthesis Mismatch ◽

The Impact ◽

Similar Risk ◽

Severe Patient

The Trifecta aortic valve has excellent hemodynamics characteristics. Moreover, the Perceval prosthesis may achieve better hemodynamics than the conventional valves; therefore, it has been proposed to reduce the incidence of patient–prosthesis mismatch. Our aim was to compare the prevalence of this complication between both prostheses. All patients who underwent valve replacement with a Perceval or a Trifecta from 2016 to 2020 at our institution were included. We calculated the prevalence of patient–prosthesis mismatch for each prosthesis and size and performed a multinomial logistic regression model to investigate the impact of choosing one prosthesis over the other. A total of 516 patients were analyzed. Moderate mismatch was present in 33 (8.6%) in the Trifecta group and 28 (21.4%) in the Perceval group, p < 0.001. Severe mismatch was present in 8 (2.1%) patients with Trifecta and 5 (3.8%) patients with Perceval, p = 0.33. Compared with the Perceval, the Trifecta prosthesis was shown to reduce moderate patient–prosthesis mismatch: OR = 0.5 (95% CI 0.3–0.9, p = 0.02). Both prostheses led to a similar risk of severe patient–prosthesis mismatch: OR = 0.9 (95% CI 0.3–2.8, p = 0.79). Both prostheses provide a very low risk of severe patient–prosthesis mismatch. Compared with the Perceval prothesis, the Trifecta prosthesis is able to reduce by 50% the risk of moderate mismatch.

Download Full-text

Speckle tracking echocardiography in severe patient–prosthesis mismatch

Herz ◽

10.1007/s00059-021-05031-4 ◽

2021 ◽

Author(s):

Altuğ Ösken ◽

Şennur Ünal Dayı ◽

Kazım Serhan Özcan ◽

Muhammed Keskin ◽

Tuğba Kemaloğlu Öz ◽

...

Keyword(s):

Speckle Tracking ◽

Speckle Tracking Echocardiography ◽

Patient Prosthesis Mismatch ◽

Severe Patient

Download Full-text

Individualized valve therapy

ESC CardioMed ◽

10.1093/med/9780198784906.003.0726 ◽

2018 ◽

pp. 2998-3001

Author(s):

Stephan Baldus ◽

Henrik ten Freyhaus

Keyword(s):

Decision Making ◽

Heart Disease ◽

Correct Diagnosis ◽

Structural Heart Disease ◽

Low Flow ◽

Heart Team ◽

Related Factors ◽

Full Spectrum ◽

Patient Prosthesis Mismatch ◽

Current Guidelines

Current guidelines offer comprehensive advice on the management of the full spectrum of valvular heart disease. However, in a significant number of patients, decision-making is a challenge. Therefore, formation of the Heart Team, which comprises cardiologists, cardiac surgeons, and other disciplines, is a critical recommendation in current guidelines. Decisions are mostly based on individual patient-related factors (e.g. severity and nature of symptoms, life expectancy, operative risk, and presence of concomitant diseases) and on comprehensive cardiovascular imaging. Here, correct diagnosis of the severity of valve disease is the first step that may already be challenging (e.g. presence of low flow across a sclerotic aortic valve). Next, the anatomy of the defect is characterized (e.g. high likelihood of patient–prosthesis mismatch, or P2 prolapse of the mitral valve), followed by screening for the presence of structural heart disease (e.g. functional mitral regurgitation in the context of posterolateral wall motion abnormality) and for impaired chamber function (e.g. reduced right ventricular function in the context of severe tricuspid regurgitation). Complete information on all these factors is the prerequisite for rational decision-making and planning of the therapeutic strategy by the Heart Team.

Download Full-text

A Retrospective Comparison of Hemodynamic and Clinical Outcomes between Two Differently Designed Aortic Bioprostheses for Small Aortic Annuli

Journal of Clinical Medicine ◽

10.3390/jcm10051063 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1063

Author(s):

Do Jung Kim ◽

Sak Lee ◽

Hyun-Chel Joo ◽

Young-Nam Youn ◽

Kyung-Jong Yoo ◽

...

Keyword(s):

Clinical Outcomes ◽

Left Ventricular ◽

Propensity Score Matching Analysis ◽

Retrospective Comparison ◽

Confounding Variables ◽

Patient Prosthesis Mismatch ◽

The Mean ◽

Post Implantation ◽

Over Time ◽

Severe Patient

The Trifecta valve has externally mounted leaflets; it differs from classic internally mounted valves (e.g., Carpentier-Edwards [C-E]). We evaluated post-implantation hemodynamics and clinical outcomes of these bioprostheses in small aortic annuli. From January 2015 to April 2019, 490 patients who underwent aortic valve replacement (AVR) were reviewed retrospectively. Altogether, 183 patients received 19 or 21 mm diameter C-E (n = 121) or Trifecta (n = 62) prostheses. To minimize confounding variables, we performed propensity-score matching analysis. The mean transvalvular pressure gradient (TVPG) was significantly lower in the Trifecta than in the C-E group at discharge (12.9 ± 4.8 vs. 15.0 ± 5.3 mmHg, p = 0.044). TVPG change over time was not significantly different between groups (p = 0.357). Left ventricular mass index decreased postoperatively (reduction: C-E, 28.1%; Trifecta, 30.1%, p = 0.879). No late mortality, severe patient–prosthesis mismatch, moderate-to-severe paravalvular leakage, structural valve degeneration, or valve thromboses were observed. Freedom from valve-related events at 3 years were similar for C-E (97.9% ± 2.1%) and Trifecta (97.7% ± 2.2%) patients (log-rank p = 0.993). Bioprosthesis design for small annuli significantly affected TVPG immediately after AVR. However, hemodynamics over time and clinical outcomes did not differ between the two designs.

Download Full-text