Valve prosthesis-patient mismatch (VP-PM): a long-term perspective

Ross procedure versus pulmonary homograft versus mechanical valve versus bioprosthetic valve versus Ozaki procedure for surgical aortic valve replacement: a frequentist network meta-analysis

BACKGROUND

There has been a resurgence in interest regarding the Ross procedure due to recent publications detailing positive long-term outcomes. Conversely, surgical aortic valve replacement (SAVR) with a pulmonary homograft (PH), mechanical (MV), bioprosthetic (BV), or the Ozaki procedure each has its own technical advantages and disadvantages. Therefore, we performed a network meta-analysis (NMA) comparing other alternatives to Ross procedure.

METHODS

Medical databases were comprehensively searched for studies comparing the Ross procedure with AVR using a PH, MV, BV, or the Ozaki procedure. Outcomes were pooled as risk ratios (RR) with their 95% confidence intervals (95% CI).

RESULTS

A total of 7816 patients were pooled for our NMA from 24 studies. Compared to Ross procedure, both BV and MV were associated with significantly higher rates of 30-day mortality of RR (2.37, 95% CI 1.20-4.67) and (1.88 95% CI 1.04-3.40), respectively, with no significant difference regarding PH or Ozaki. However, only MV was associated with a higher risk of 30-day stroke (RR 8.42, 95% CI 1.57-45.23) with no significant difference in the other alternatives, as well as 30-day MI which showed no significant differences between any of the aortic conduits compared to the Ross procedure. Regarding 30-day major bleeding, MV was associated with a higher when compared to the Ross procedure RR (4.58, 95% CI 1.94-10.85), PH was associated with a lower risk of major bleeding with RR (0.35, 95% CI 0.17-0.71), and BV showed no significant difference. With a mean follow-up duration of 8.5 years compared to the Ross procedure, BV, PH, and MV were associated with a higher risk of long-term mortality with RR (1.89, 95% CI 1.38-2.58), (1.38, 95% CI 1.0-1.87), and (1.94, 95% CI 1.52-2.47), respectively, with the Ozaki procedure showed no significant difference. Regarding long-term stroke-with a mean of 6.3-year follow-up duration-there were no significant differences between any of the aortic conduits compared to the Ross procedure. Nevertheless, long-term need for reintervention-with a mean follow-up duration of 17.5 years-was significant of higher risk with both BV and PH with RR (3.28, 95% CI 1.21-8.84) and (2.42, 95% CI 1.05-5.58), respectively, compared to Ross procedure with MV and Ozaki having no significant difference.

CONCLUSIONS

The Ross procedure is a viable treatment option for patients undergoing SAVR, showing promising outcomes at short- and long-term follow-ups.

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

BACKGROUND

It 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).

OBJECTIVES

The purpose of this study is to evaluate the time-varying effects and association of PPM with the risk of overall mortality.

METHODS

Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of studies published by December 30, 2021.

RESULTS

In 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).

CONCLUSIONS

Severe 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.

TAVR in 2023: Who Should Not Get It?

Since the first transcatheter delivery of an aortic valve prosthesis was performed by Cribier et al in 2002, the picture of aortic stenosis (AS) therapeutics has changed dramatically. Initiated from an indication of inoperable to high surgical risk, extending to intermediate and low risk, transcatheter aortic valve replacement (TAVR) is now an approved treatment for patients with severe, symptomatic AS across all the risk categories. The current evidence supports TAVR as a frontline therapy for treating severe AS. The crucial question remains concerning the subset of patients who still are not ideal candidates for TAVR because of certain inherent anatomic, nonmodifiable, and procedure-specific factors. Therefore, in this study, we focus on these scenarios and reasons for referring selected patients for surgical aortic valve replacement in 2023.

Improved Outcomes Following the Ross Procedure Compared With Bioprosthetic Aortic Valve Replacement

BACKGROUND

The ideal aortic valve substitute for young and middle-aged adults remains elusive.

OBJECTIVES

This study sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving bioprosthetic aortic valve replacements (AVRs).

METHODS

Consecutive patients aged 16-60 years who underwent a Ross procedure or surgical bioprosthetic AVR at the Toronto General Hospital between 1990 and 2014 were identified. Propensity score matching was used to account for differences in baseline characteristics. The primary outcome was all-cause mortality. Secondary outcomes included valve reintervention, valve deterioration, endocarditis, thromboembolic events, and permanent pacemaker implantation.

RESULTS

Propensity score matching yielded 108 pairs of patients. The median age was 41 years (IQR: 34-47 years). Baseline characteristics were similar between the matched groups. There was no operative mortality in either group. Mean follow-up was 14.5 ± 7.2 years. All-cause mortality was lower following the Ross procedure (HR: 0.35; 95% CI: 0.14-0.90; P = 0.028). Using death as a competing risk, the Ross procedure was associated with lower rates of reintervention (HR: 0.21; 95% CI: 0.10-0.41; P < 0.001), valve deterioration (HR: 0.25; 95% CI: 0.14-0.45; P < 0.001), thromboembolic events (HR: 0.15; 95% CI: 0.05-0.50; P = 0.002), and permanent pacemaker implantation (HR: 0.22; 95% CI: 0.07-0.64; P = 0.006).

CONCLUSIONS

In this propensity-matched study, the Ross procedure was associated with better long-term survival and freedom from adverse valve-related events compared with bioprosthetic AVR. In specialized centers with sufficient expertise, the Ross procedure should be considered the primary option for young and middle-aged adults undergoing AVR.

Racial Differences in the Incidence and Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement

OBJECTIVES

The aim of this study was to compare the incidence and prognostic significance of prosthesis-patient mismatch (PPM) after transcatheter aortic valve replacement (TAVR) according to racial groups.

BACKGROUND

PPM after TAVR may be of more concern in Asian populations considering their relatively small annular and valve sizes compared with Western populations.

METHODS

TP-TAVR (Transpacific TAVR Registry) was an international multicenter cohort study of patients with severe aortic stenosis who underwent TAVR in the United States and South Korea from January 2015 to November 2019. PPM was defined as moderate (0.65-0.85 cm²/m²) or severe (<0.65 cm²/m²) at the indexed effective orifice area. The primary outcome was a composite of death, stroke, or rehospitalization at 1 year.

RESULTS

Among 1,101 eligible patients (533 Asian and 569 non-Asian), the incidence of PPM was significantly lower in the Asian population (33.6%; moderate, 26.5%; severe, 7.1%) than in the non-Asian population (54.5%; moderate, 29.8%; severe, 24.7%). The 1-year rate of the primary outcome was similar between the PPM and non-PPM groups (27.5% vs 28.1%; P = 0.69); this pattern was consistent between Asian (25.4% vs 25.2%; P = 0.31) and non-Asian (28.7% vs 32.1%; P = 0.97) patients. After multivariable adjustment, the risk for the primary outcome did not significantly differ between the PPM and non-PPM groups in the overall population (HR: 0.95; 95% CI: 0.74-1.21), in Asian patients (HR: 1.07; 95% CI: 0.74-1.55), and in non-Asian patients (HR: 0.86; 95% CI: 0.63-1.19).

CONCLUSIONS

In this study of patients with severe aortic stenosis who underwent TAVR, the incidence of PPM was significantly lower in Asian patients than in non-Asian patients. The 1-year risk for the primary composite outcome was similar between the PPM and non-PPM groups regardless of racial group. (Transpacific TAVR Registry [TP-TAVR]; NCT03826264).

Aortic closure signal length on doppler echocardiography differentiates aortic patient-prosthesis mismatch from prosthetic stenosis

PURPOSE

The purpose of this study was to investigate the diagnostic potential of the aortic closure (A2) signal length on Doppler echocardiography in distinguishing aortic patient-prosthesis mismatch (PPM) from prosthetic stenosis among patients with elevated gradients over bioprosthetic valves.

METHODS

The A2 signal length was retrospectively measured for 150 patients with bioprosthetic aortic valves (50 with PPM, 50 with prosthetic stenosis, and 50 with normally functioning valves) from transthoracic echocardiograms performed at NYU Langone Health between 01/01/2012 and 08/01/2018.

RESULTS

Mean A2 signal length was shorter among patients with PPM (11.1 ms ± 5.2 ms), than among those with prosthetic stenosis (21.1 ms ± 6.0 ms), P < .001 and controls (21.7 ms ± 7.4 ms), P < .001. There was no difference in A2 signal length between prosthetic stenosis and controls. The A2 signal length yielded an AUC of 0.89 (95% CI 0.82-0.95) for predicting PPM over prosthetic stenosis.

CONCLUSION

Among patients with bioprosthetic aortic valves, the length of the A2 signal on Doppler echocardiography is shorter in PPM than in prosthetic stenosis and normally functioning valves. The A2 signal length may represent a novel metric to distinguish PPM from prosthetic stenosis.

Prosthesis-patient mismatch affects late survival after valve surgery for severe aortic stenosis

BACKGROUND

The effect of prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) in patient with symptomatic severe aortic stenosis (AS) remains unclear. Also, late follow-up in previous studies is confined to only one decade. We aimed to determine the effect of PPM on late survival after isolated AVR for symptomatic severe AS during 25 years of follow-up.

METHODS

In this retrospective cohort study, Kaplan-Meier survival analysis was performed to determine late survival in 404 consecutive patients with moderate PPM (N.=86), severe (N.=11), or no/mild PPM (N.=307) after isolated AVR for symptomatic severe AS during a mean follow-up of 25.0±2.9 years. Moderate, severe, and no/mild PPM were defined as indexed effective orifice area of >0.65≤0.85, ≤0.65, and >0.85 cm2/m2, respectively. Multivariable analysis was performed to identify possible independent predictors of decreased late survival, including moderate or severe PPM.

RESULTS

Late survival of patients with severe PPM was worse in comparison with those with no/mild PPM: 7.4±2.6 (95% confidence interval 2.2-12.5) vs. 13.6±0.5 (95% confidence interval 12.6-14.6) years, respectively; P=0.020. Late survival of patients with moderate PPM was similar to those with no/mild PPM. Severe PPM was an independent predictor of decreased late survival: hazards ratio 4.002 (95% confidence interval 1.869-8.569); P<0.001. Moderate PPM was not an independent predictor of decreased late survival.

CONCLUSIONS

Severe PPM was independently associated with decreased late survival after isolated AVR for symptomatic severe AS during a mean follow-up of 25.0±2.9 years. Therefore, severe PPM should be prevented as much as possible.

Outcomes of Prosthesis-Patient Mismatch Following Supra-Annular Transcatheter Aortic Valve Replacement: From the STS/ACC TVT Registry

OBJECTIVES

The aim of this study was to assess the outcomes of severe prosthesis-patient mismatch (PPM) in the TVT (Transcatheter Valve Therapy) Registry in patients undergoing supra-annular transcatheter aortic valve replacement (TAVR) for de novo stenosis or failed surgical bioprostheses (transcatheter aortic valve [TAV]-in-surgical aortic valve [SAV]).

BACKGROUND

Severe PPM has been associated with adverse outcomes following TAVR, yet the clinical outcome of severe PPM after supra-annular TAVR is largely unknown.

METHODS

Supra-annular TAVR was performed in patients enrolled in the TVT Registry with de novo stenosis (n = 42,174) or TAV-in-SAV (n = 5,446). Valve Academic Research Consortium-3 criteria were used to define severe PPM. The clinical impact of severe PPM on 1-year mortality and valve-related readmission was assessed using multivariate regression. A generalized linear mixed model was used to evaluate predictors of severe PPM.

RESULTS

Severe PPM was found in 5.3% of patients undergoing de novo TAVR and 27.0% of patients undergoing TAV-in-SAV. The presence of severe PPM was not significantly associated with 1-year mortality or valve-related readmissions in both groups. Mean aortic gradients were higher in patients with severe PPM than in those without severe PPM at 1 month (9.7 ± 5.7 mm Hg vs. 7.3 ± 4.0 mm Hg; p < 0.001) and 1 year (10.2 ± 6.4 mm Hg vs. 8.0 ± 4.3 mm Hg; p < 0.001). Pre-procedural factors, including a <20-mm aortic annulus, were positive predictors of severe PPM in patients undergoing de novo TAVR (area under the curve = 0.795) and TAV-in-SAV (area under the curve = 0.764).

CONCLUSIONS

Severe PPM after supra-annular TAVR was not associated with increased 1-year mortality or valve-related readmissions. Longer-term follow-up is needed to determine if higher residual gradients in patients with severe PPM predict long-term outcomes. (STS/ACC Transcatheter Valve Therapy Registry [TVT Registry]; NCT01737528).

Speckle tracking echocardiography in severe patient-prosthesis mismatch

BACKGROUND

Although aortic valve replacement (AVR) when successfully performed boasts low mortality rates in selected patients, prosthesis-patient mismatch (PPM) can be found in the majority of these individuals. Limited research is available supporting the benefit of two-dimensional speckle tracking echocardiography (2D-STE) in patients with severe PPM. This study sought to assess myocardial strain using 2D-STE to determine the relationship between subclinical left ventricular (LV) dysfunction and aortic PPM in patients undergoing AVR with preserved LV ejection fraction.

MATERIAL AND METHODS

We retrospectively examined all consecutive patients with isolated AVR who presented to our center from 2005 to 2018. The data of 1086 patients were analyzed. Severe PPM was defined as an indexed effective orifice area of 0.65 cm²/m² or less. As a result of the detailed assessment, 54 patients meeting the eligibility criteria were included in the study. Baseline data were collected and compared between the two groups of patients with severe PPM (n = 27) and those with normofunctional aortic prosthesis valve as a control group (n = 27). All patients underwent baseline echocardiography. Global longitudinal strain (GLS) and global circumferential strain (GCS) were evaluated by 2D-STE.

RESULTS

When compared with controls, patients with severe PPM had significantly decreased GLS (18.6 ± 2.9 vs. 21.4 ± 2.1; p < 0.01) and GCS (17.2 ± 3.6 vs. 21.7 ± 2.1; p < 0.01) values.

CONCLUSION

In addition to standard clinical and echocardiographic parameters, GLS and GCS suggest subclinical dysfunction and have incremental value in patients with severe PPM.

Impact of valve size, predicted effective and indexed effective orifice area after aortic valve replacement

INTRODUCTION

The impact of manufacturer labeled prosthesis size and predicted effective orifice area (EOA) on long-term survival after aortic valve replacement is not clear although indexed effective orifice area (iEOA) has been associated with worse survival.

METHODS

Data was retrospectively collected from Jan 2000-Dec 2019 for prosthesis type, model, and size for isolated aortic valve replacements. Stratified survival was compared between groups and subgroups for labeled valve size, EOA and predicted patient prosthesis mismatch (PPM).

RESULTS

A total of 3444 patients were included. Moderate and severe PPM was 15.6% and 1.6%, respectively. Cumulative lifetime hazard was worse for biological valves (mortality: biological 77.7% vs. mechanical 64.8%, p = .001). Moderate prosthetic aortic stenosis (AS), (EOA = 1-1.5 cm² ) was 12.1% and severe prosthetic AS (EOA ≤ 1 cm² ) was 0.8%, respectively. Survival was 10.5 ± 0.4 years with moderate to severe prosthetic AS (EOA≤1.5 cm² ) versus 12.6 ± 0.2 years with mild to no prosthetic AS (EOA>1.5 cm² ), p = .001. Worse survival in the presence of moderate-severe prosthetic AS was seen with biological valves (9.7 ± 0.4 years vs. 11.2 ± 0.2 years, p = .001 for EOA≤1.5, >1.5 cm² , respectively). Moderate to severe PPM was associated with worse survival (11.1 ± 0.4 years for iEOA ≤ 0.85 cm² /m² vs. 12.5 ± 0.2 years with iEOA > 0.85 cm² /m² , p = .001). Moderate to severe PPM predicted worse long term survival (hazard ratio: 3.56; 95% confidence interval: 1.37-9.25; p = .009).

CONCLUSION

Predicted prosthetic moderate to severe AS and moderate to severe PPM adversely affect long term survival. Smaller valves are associated with reduced survival.

Patient-prosthesis mismatch in mitral annuloplasty for degenerative mitral regurgitation: an ignored issue

OBJECTIVES

Elevated postoperative transmitral gradient (TMG), partially induced by a small annuloplasty ring, is associated with late atrial fibrillation (AF) after mitral valve repair. Here, we aimed to provide the optimal cut-off of prosthetic ring size to reduce patient-prosthesis mismatch (PPM) after mitral annuloplasty.

METHODS

From 2006 to 2017, 262 patients who underwent mitral valve repair for degenerative pathologies were retrospectively studied. The relationships of body surface area (BSA)-indexed prosthetic orifice area (POAi)-postoperative TMG and POAi-late AF were tested using regression curves and receiver operating characteristic curves, respectively. The optimal cut-off of POAi predictive of late AF was used to define PPM. Baseline and follow-up data of patients with and without PPM were compared in propensity score-matched cohorts.

RESULTS

In-hospital mortality was 0. Late AF was observed in 9.2% (24/262) patients during a median follow-up of 3.8 years. An exponential model was best fitted based on the POAi-postoperative TMG relationship (P < 0.001). Using late AF as the dependent variable, the optimal cut-off for PPM was POAi ≤2.28 cm2/m2 (c-statistic 0.71; sensitivity 0.61; specificity 0.80; P < 0.001). PPM was identified in 113 (43.1%) patients. After propensity score matching, the estimated 5-year rate of late AF was significantly higher in PPM patients than in non-PPM patients (24% vs 5%; P < 0.001).

CONCLUSIONS

Postoperative TMG increases significantly with a small POAi for full ring annuloplasty. A patient's BSA should be considered in addition to valvular dimensions during the selection of a proper ring size to reduce PPM-related AF.

Autologous pericardial aortic valve reconstruction: early results and comparison with mechanical valve replacement

Introduction

Autologous pericardial aortic valve reconstruction is an attractive option compared with prosthetic valve replacement due to the absence of anticoagulation, lower pressure gradient across the valve and excellent valve haemodynamics.

Objective

We wanted to share the early results of autologous pericardial aortic valve reconstruction from our centre. The outcomes were compared with that of mechanical valve replacement.

Materials and methods

Between August 2016 to July 2018, 20 patients underwent autologous aortic valve reconstruction as per the techniques described by Ozaki et al. The surgery was done for aortic stenosis or regurgitation or a combination of both. All the surgeries were done by a single experienced surgeon. The results were compared to that of mechanical valve replacement. A comprehensive echocardiographic evaluation was done pre-discharge and at 6 months after surgery. The postoperative echocardiographic parameters that were evaluated include aortic valve pressure gradient, aortic valve orifice area, ejection fraction, left ventricular diameters etc. All the parameters were measured by a single expert. Other perioperative parameters were also evaluated like cardiopulmonary bypass and cross-clamp time, need for anticoagulation etc. Statistical analysis was done using chi-square test/Mann-Whitney U test/independent sample t test.

Results

Autologous pericardial aortic valve reconstruction had several favourable results including lower aortic valve pressure gradient, bigger aortic valve orifice area etc. None of the patients required anticoagulation. There were no conversions to prosthetic valve replacement or reinterventions in the follow-up period.

Conclusion

Autologous pericardial aortic valve reconstruction is a feasible alternative to prosthetic valve replacement with several advantages.

Perceval or Trifecta to Prevent Patient-Prosthesis Mismatch

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.

In vitro comparison of everting vs. non-everting suture techniques for the implantation of a supra-annular biological heart valve

Background

The aim of this study was to evaluate the hemodynamic effect of different suturing techniques for aortic valve replacement (AVR) in vitro. Whether or not the applied suturing technique impacts the outflow tract diameter by narrowing the annulus diameter was examined.

Methods

The commonly applied non-everting pledget forced suture technique (NE, n=13) was compared with an everting pledget forced suture (ET, n=13) for AVR using the 25 mm St. Jude Trifecta aortic valve. Hemodynamic parameters were obtained in a pulsatile flow simulator. A high speed camera captured the visual aspects of the suturing technique.

Results

Despite some kind of left ventricular outflow narrowing due to protruding pledgets using the NE suture technique, mean pressure gradients of both techniques were nearly similar (NE 5.88±2.7 mmHg, ET 5.23±1.31 mmHg, P=0.44). Closing volume (NE 3.16±0.48 mL; ET 3.51±0.68 mL; P=0.14) and the leakage volume (NE: 8.09±2.53 mL; ET: 8.35±3.65 mL; P=0.83) also showed no differences.

Conclusions

AVR using either suturing techniques leads to a similar hemodynamic performance in vitro. The impact of the suturing technique may be higher in a smaller annulus. Therefore, further studies using smaller prostheses are necessary.

Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis?

Background

Prosthesis-patient mismatch (PPM) is associated with worse outcomes.

Objective

Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care.

Methods

A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm²/m²), mild to moderate PPM (iEOA, 0.65 cm²/m² - 0.85 cm²/m²) and without PPM (iEOA > 0.85 cm²/m²) for a BMI < 30 kg/m² and severe PPM (iEOA) < 0.55 cm²/m²), mild to moderate (iEOA, 0.55 cm²/m²- 0.70 cm²/m²) and without PPM (iEOA > 0.7 cm²/m²) for a BMI > 30 kg/m². Statistical significance was considered when p < 0.05.

Results

iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m², age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82.

Conclusion

The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.

Global longitudinal strain in prosthesis-patient mismatch: relation to left ventricular mass regression and outcomes

AIMS

Aortic prosthesis-patient mismatch (PPM) increases left ventricular (LV) afterload and prevents LV mass regression (LVMR) after surgery. This study was designed to investigate the association between the baseline global longitudinal strain (GLS) and the postoperative LVMR, and its relation to adverse outcomes.

METHODS

A total of 316 patients with aortic stenosis undergoing isolated mechanical prosthesis implantation were screened, and data from 91 patients with aortic PPM and 165 non-PPM patients were retrospectively collected. All 256 patients underwent measurement of GLS by two-dimensional speckle-tracking echocardiography preoperatively, and were followed up for postoperative changes of LV mass index (LVMi) and other clinical outcomes.

RESULTS

During the follow-up, LVMi in PPM patients decreased significantly from 139.6 ± 20.8 to 119.6 ± 26.5 g/m (P < 0.001). These patients were divided into two groups according to the median value of the reduction rate of LVMi at final follow-up, and preoperative GLS markedly decreased in PPM patients with insignificant reduction in LVMi. Multivariate analysis identified preoperative GLS (odds ratio 3.45, 95% confidence interval 1.27-11.05, P = 0.002) and preoperative LVMi (odds ratio 2.87, 95% confidence interval 1.21-8.13, P = 0.012) as independently associated with an insignificant LVMR. Moreover, PPM patients with limited reduction in LVMi were at an increased risk of cardiac death and major adverse valve-related events.

CONCLUSION

In patients with aortic PPM early after surgery, reduced preoperative GLS could be a novel sensitive risk factor for a limited regression of LV hypertrophy, and this is associated with an increased risk of adverse events in PPM patients.

Clinical outcome and hemodynamic performance of St. Jude Trifecta aortic prosthesis: short-term follow-up and risk factors analysis

BACKGROUND

We retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis.

METHODS

Between December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%.

RESULTS

Trifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015).

CONCLUSIONS

Trifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.

Limitations in the Assessment of Prosthesis-Patient Mismatch

Background Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area (EOA) to body surface area (EOAi). EOA is patient-specific as the result of flow-velocity times area at the individual patient's outflow tract levels (LVOTA) divided by trans-prosthetic flow velocity. However, some studies use projected EOAs (i.e., valve size associated EOAs from other patient populations) to assess how PPM affects outcome.

Methods We analyzed 76 studies addressing hemodynamic outcome and/or mortality after bioprosthetic AVR.

Results In 48 studies, projected or measured EOA for calculation of EOAi and PPM assessment was used (of which 25 demonstrated an effect on survival). We identified 28 additional studies providing measured EOA values and the corresponding Bernoulli's pressure gradients after AVR. Despite EOA being a patient-specific parameter, 77% of studies assessing a PPM impact on survival used projected EOAs. The 28 studies are providing measured EOA values and the corresponding Bernoulli's pressure gradients in patients after AVR showed a highly significant, linear relationship between EOA and Bernoulli's gradient. Considering this relationship, it is surprising that relating EOA to body surface area (BSA) (EOAi) is standard but relating pressure gradients to BSA is not.

Conclusion We conclude that the majority of studies assessing PPM have used false assumptions because EOA is a patient-specific parameter and cannot be transferred to other patients. In addition, the use of EOAi to assess PPM may not be appropriate and could explain the inconsistent relation between PPM and survival in previous studies.

The Prognostic Significance of Patient-Prosthesis Mismatch after Aortic Valve Replacement

Patient-prosthesis mismatch (PPM) is a controversial issue in current clinical practice. PPM has been reported to have a negative impact on patients’ prognosis after aortic valve replacement in several studies, showing increased all-cause and cardiac mortality. Moreover, a close relationship has recently been described between PPM and structural valve deterioration in biological prostheses. In patients at risk for PPM, several issues should be considered, and in the current era of cardiac surgery, preoperative planning should consider the different types of valves available and the various surgical techniques that can be used to prevent PPM. The present paper analyses the state of the art of the PPM issue.

Progressive breathlessness following transcatheter aortic valve replacement

: An 84-year-old man presented urgently to the cardiology clinic with rapid onset exertional dyspnoea while walking on the flat. Five months previously, he underwent implantation of a balloon-expandable 26 mm transcatheter heart valve (SAPIEN 3, Edwards Lifesciences) for severe aortic stenosis. On clinical examination, the jugular venous pressure was elevated and a mid-late ejection systolic murmur was audible in the aortic region. ECG demonstrated sinus rhythm with a left ventricular (LV) strain pattern. Transthoracic echocardiography and cardiac CT were performed (figure 1). heartjnl;103/21/1703/F1F1F1Figure 1(A) Transthoracic continuous wave Doppler through the transcatheter AV. ECG-gated cardiac CT oblique reconstruction of the LV outflow tract and aortic root in mid-diastole (B) with axial reconstruction of the transcatheter AV in end-systole (inset). AT, acceleration time; AV, aortic valve; LV, left ventricular.

QUESTION

Which aetiology best explains this presentation?Pannus formationTranscatheter bioprosthetic valve endocarditisPatient-prosthesis mismatchTranscatheter bioprosthetic valve leaflet thrombosisStructural valve degeneration.

Blood Pressure and Arterial Load After Transcatheter Aortic Valve Replacement for Aortic Stenosis

Background—

After aortic valve replacement, left ventricular afterload is often characterized by the residual valve obstruction. Our objective was to determine whether higher systemic arterial afterload—as reflected in blood pressure, pulsatile and resistive load—is associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR).

Methods and Results—

Total, pulsatile, and resistive arterial load were measured in 2141 patients with severe aortic stenosis treated with TAVR in the PARTNER I trial (Placement of Aortic Transcatheter Valve) who had systolic blood pressure (SBP) and an echocardiogram obtained 30 days after TAVR. The primary end point was 30-day to 1-year all-cause mortality. Lower SBP at 30 days after TAVR was associated with higher mortality (20.0% for SBP 100–129 mm Hg versus 12.0% for SBP 130–170 mm Hg; P <0.001). This association remained significant after adjustment, was consistent across subgroups, and confirmed in sensitivity analyses. In adjusted models that included SBP, higher total and pulsatile arterial load were associated with increased mortality ( P <0.001 for all), but resistive load was not. Patients with low 30-day SBP and high pulsatile load had a 3-fold higher mortality than those with high 30-day SBP and low pulsatile load (26.1% versus 8.1%; hazard ratio, 3.62; 95% confidence interval, 2.36–5.55).

Conclusions—

Even after relief of valve obstruction in patients with aortic stenosis, there is an independent association between post-TAVR blood pressure, systemic arterial load, and mortality. Blood pressure goals in patients with a history of aortic stenosis may need to be redefined. Increased pulsatile arterial load, rather than blood pressure, may be a target for adjunctive medical therapy to improve outcomes after TAVR.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894

Performance of the Labcor Dokimos Plus pericardial aortic prosthesis: a single-centre experience

Objectives

In patients with a small aortic annulus, aortic valve replacement (AVR) is frequently associated with high residual pressure gradients. Supra-annular pericardial aortic prostheses are gaining popularity due to the increased effective orifice areas (EOA) and resulting lower gradients. This study reports the clinical and echocardiographic results following implantation of the new supra-annular pericardial aortic prosthesis Dokimos Plus (Labcor, Belo Horizonte, Brazil).

Methods

Between October 2013 and July 2015, 137 patients (41% women, mean age: 74 years) underwent supra-annular AVR with or without concomitant procedures using the Dokimos Plus prosthesis in our department. Transthoracic echocardiography was performed pre- and postoperatively on all patients to assess haemodynamic parameters (gradients, acceleration time [AT], Doppler velocity indices [DVIs] and indexed EOA [EOAI]) and to detect paravalvular leakage (PVL). Data were collected retrospectively from our hospital databases.

Methods

Patients were grouped by prosthesis size: Most patients received 23-mm (57.6%), followed by 21-mm (19%), 25-mm (15.4%) and 27-mm (8%) prostheses. The mean EOAI in all groups was 1.1 ± 0.26 cm 2 /m 2 . Pressure gradients were low in all groups (mean: 8.9 ± 4.4 mmHg; peak: 18.8 ± 6.8 mmHg); AT and DVI were in the normal range according to American Society of Echocardiography/European Association of Cardiovascular Imaging recommendations (mean AT 73.3 ± 29 ms; mean DVI 0.5 ± 0.2). One patient had severe PVL and one presented with central regurgitation, both requiring re-intervention. The mortality rate was 5.1% ( n  = 7); none of the cases was associated with valve insufficiency.

Conclusions

The Dokimos prosthesis showed a satisfactory overall performance, presenting low gradients and DVIs as well as high EOAI. Further investigations are needed to analyse the cases of regurgitation and monitor long-term performance.

On the Mechanics of Transcatheter Aortic Valve Replacement

Transcatheter aortic valves (TAVs) represent the latest advances in prosthetic heart valve technology. TAVs are truly transformational as they bring the benefit of heart valve replacement to patients that would otherwise not be operated on. Nevertheless, like any new device technology, the high expectations are dampened with growing concerns arising from frequent complications that develop in patients, indicating that the technology is far from being mature. Some of the most common complications that plague current TAV devices include malpositioning, crimp-induced leaflet damage, paravalvular leak, thrombosis, conduction abnormalities and prosthesis-patient mismatch. In this article, we provide an in-depth review of the current state-of-the-art pertaining the mechanics of TAVs while highlighting various studies guiding clinicians, regulatory agencies, and next-generation device designers.

Patient prosthesis mismatch after aortic valve replacement: An Indian perspective

CONTEXT

Perioperative period.

AIMS

Occurrence of PPM after AVR, factors associated with PPM, impact on mortality.

SETTINGS AND DESIGN

Teritary Care Referral Cardiac Centre.

MATERIALS AND METHODS

A retrospective analysis of AVR procedures at a single centre over 4 years was conducted. Demographic, echocardiographic and outcome data were collected from institute database. Rahimtoola criteria of indexed effective orifice area (iEOA) were used to stratify patients into PPM categories. Patients with and without PPM were compared for associated factors.

STATISTICAL ANALYSIS USED

Independent t-test, chi-square test, logistic regression analysis, ROC-AUC, Youden index.

RESULTS

606 patients with complete data were analysed for PPM. The incidence of mild, moderate and severe PPM was 6.1% (37), 2.5% (15) and 0.5% (3) respectively. There was no impact of PPM on all-cause in-hospital mortality. PPM was observed more with Aortic Stenosis (AS) compared to Aortic Regurgitation (AR) as etiology. Aortic annulus indexed to BSA (iAA) had a very good predictive ability for PPM at <16mm/m 2 BSA.

CONCLUSIONS

PPM has lower incidence after AVR in this Indian population and does not increase early mortality. Patients with AS and iAA<16mm/m2BSA should be cautiously dealt with to prevent PPM.

Does patient-prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients?

BACKGROUND

To evaluate the impact of patient-prosthesis mismatch (PPM) on survival, functional status, and quality of life (QoL) after aortic valve replacement (AVR) with small prosthesis size in elderly patients.

METHODS

Between January 2005 and December 2013, 152 patients with pure aortic stenosis, aged at least 75 years, underwent AVR, with a 19 or 21 mm prosthetic heart valve. PPM was defined as an indexed effective orifice area less than 0.85 cm/m. Median age was 82 years (range 75-93 years). Mean follow-up was 56 months (range 1-82 months) and was 98% complete. Late survival rate, New York Heart Association functional class, and QoL (RAND SF-36) were assessed.

RESULTS

Overall, PPM was found in 78 patients (53.8%). Among them, 42 patients (29%) had an indexed effective orifice area less than 0.75 cm/m and 17 less than 0.65 cm/m (11.7%). Overall survival at 5 years was 78 ± 4.5% and was not influenced by PPM (P = NS). The mean New York Heart Association class for long-term survivors with PPM improved from 3.0 to 1.7 (P < 0.001). QoL (physical functioning 45.18 ± 11.35, energy/fatigue 49.36 ± 8.64, emotional well being 58.84 ± 15.44, social functioning 61.29 ± 6.15) was similar to that of no-PPM patients (P = NS).

CONCLUSION

PPM after AVR does not affect survival, functional status, and QoL in patients aged at least 75 years. Surgical procedures, often time-consuming, contemplated to prevent PPM, may therefore be not justified in this patient subgroup.

Heart valve health, disease, replacement, and repair: a 25-year cardiovascular pathology perspective

The past several decades have witnessed major advances in the understanding of the structure, function, and biology of native valves and the pathobiology and clinical management of valvular heart disease. These improvements have enabled earlier and more precise diagnosis, assessment of the proper timing of surgical and interventional procedures, improved prosthetic and biologic valve replacements and repairs, recognition of postoperative complications and their management, and the introduction of minimally invasive approaches that have enabled definitive and durable treatment for patients who were previously considered inoperable. This review summarizes the current state of our understanding of the mechanisms of heart valve health and disease arrived at through innovative research on the cell and molecular biology of valves, clinical and pathological features of the most frequent intrinsic structural diseases that affect the valves, and the status and pathological considerations in the technological advances in valvular surgery and interventions. The contributions of many cardiovascular pathologists and other scientists, engineers, and clinicians are emphasized, and potentially fruitful areas for research are highlighted.

Comparable long-term results for porcine and pericardial prostheses after isolated aortic valve replacement

OBJECTIVES

Outcome of aortic valve replacement may be influenced by the choice of bioprosthesis. Pericardial heart valves are described to have a favourable haemodynamic profile compared with porcine valves, although the clinical notability of this finding is still controversially debated. Herein, we compared the long-term results of two commonly implanted bioprosthesis at a single centre.

METHODS

All consecutive patients undergoing isolated aortic valve replacement with either a Carpentier-Edwards Magna pericardial prosthesis or a Medtronic Mosaic porcine prosthesis between 2002 and 2008 were analysed regarding preoperative characteristics, short- and long-term survival, valve-related complications and echocardiographic findings.

RESULTS

The Medtronic Mosaic was implanted in 163 patients and the Carpentier-Edwards Magna in 295 patients. The sizes of implanted valves were 22.4 ± 1.5 mm for the Mosaic and 21.8 ± 1.8 mm for the Magna (P = 0.001). The long-term survival rate was 76 and 56% after 5 and 10 years for the Medtronic Mosaic, which was comparable with the Carpentier-Edwards Magna (77 and 57%; P = 0.92). Overall long-term survival was comparable with an age- and sex-matched Austrian general population for both groups. Valve-related adverse events were similar between groups. The postoperative mean transvalvular gradient was significantly increased in the Mosaic group (24 ± 9 mmHg vs 17 ± 7 mmHg; P < 0.001).

CONCLUSIONS

Both types of aortic bioprostheses offer excellent results after isolated aortic valve replacement. Despite relevant differences in gradients, long-term survival was comparable with the expected normal survival for both bioprostheses. Patients with a porcine heart valve had a higher postoperative transvalvular gradient.