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Kalogerakos PD, Kontopodis N, Ioannou CV, Kladou E, Chalkiadakis G, Athanasiou T, Lazopoulos G. Hemodynamics and reverse remodeling associated with Mosaic, Perimount and Trifecta aortic bioprostheses. Expert Rev Med Devices 2019; 16:743-751. [PMID: 31318302 DOI: 10.1080/17434440.2019.1642105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: The implantation rate of aortic bioprostheses is increasing. Their durability has improved to some extent over the years and they allow for future transcatheter valve-in-valve deployment. In the lack of long term follow up, their hemodynamic profile, i.e. transvalvular mean pressure gradient and effective orifice area indexed, and the associated left ventricular reverse remodeling indexed are useful surrogates for clinical outcomes. Areas covered: A systematic review of the literature was conducted by searching Medline, Cochrane, Scielo, Embase databases, and grey literature until July 2018 for articles that perform comparisons among the three most popular aortic bioprostheses. Six randomized and 12 non-randomized studies were included with 565 patients receiving a Mosaic, 1334 a Perimount and 557 a Trifecta valve. These articles are heterogeneous but they allow the meta-analytic comparison of the abovementioned outcomes. Expert opinion: Compared to the Perimount valve, the Mosaic is hemodynamically inferior, while the Trifecta is superior. Despite these statistically significant differences, the left ventricular mass regression indexed, that is indicative of reverse remodeling, was comparable in all groups. All patients were similarly benefited. The predilection among these valves is fueled by their hemodynamic profile but not supported by the comparable reverse remodeling.
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Affiliation(s)
- Paris D Kalogerakos
- a Cardiothoracic Surgery Division, University Hospital of Heraklion , Crete , Greece
| | - Nikolaos Kontopodis
- b Vascular Surgery Division, University Hospital of Heraklion , Crete , Greece
| | - Christos V Ioannou
- b Vascular Surgery Division, University Hospital of Heraklion , Crete , Greece
| | - Eleni Kladou
- c Internal Medicine Department, University Hospital of Heraklion , Crete , Greece
| | - George Chalkiadakis
- a Cardiothoracic Surgery Division, University Hospital of Heraklion , Crete , Greece
| | - Thanos Athanasiou
- d Faculty of Medicine, Department of Surgery and Cancer, Imperial College London , London , UK
| | - George Lazopoulos
- a Cardiothoracic Surgery Division, University Hospital of Heraklion , Crete , Greece
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Abraham S, Kumar AS, Kumar AS. Bioprosthetic valves — An initial experience. Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-002-0018-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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3
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Guo L, Zheng J, Chen L, Li R, Ma L, Ni Y, Zhao H. Impact of prosthesis-patient mismatch on short-term outcomes after aortic valve replacement: a retrospective analysis in East China. J Cardiothorac Surg 2017; 12:42. [PMID: 28545592 PMCID: PMC5445281 DOI: 10.1186/s13019-017-0596-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Accepted: 05/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prosthesis-patient mismatch (PPM) may affect the clinical outcomes of patients undergoing aortic valve replacement (AVR). We aimed to determine the incidence of PPM, its effect on short-term mortality, and the factors contributing to PPM in China. METHODS We retrospectively examined all consecutive patients with isolated or concomitant AVR at our hospital between January 1, 2013 and December 31, 2015. PPM was defined as an effective orifice area index (EOAi) of ≤ 0.85 cm2/m2. The baseline, echocardiographic, operative, and outcome data of all patients were collected from the national database. RESULTS A total of 869 patients were included in the study. PPM was detected in 15.9% (138/869) of the patients. Four patients (0.5%) met the criteria for severe PPM. Patients with PPM were older and had a higher prevalence of diabetes, coronary heart disease, aortic stenosis (AS), and preoperative left ventricular dysfunction but a lower incidence of smoking history and aortic regurgitation. Logistic regression analysis showed that female gender (P < 0.001), AS (P = 0.014), higher body mass index (BMI) (P < 0.001), and bioprosthesis (P < 0.001) were independent predictors of PPM. We also found that PPM (P = 0.005) was associated with 30-day all-cause mortality, along with smoking history (P = 0.001) and low preoperative left ventricular ejection fraction (LVEF) (P = 0.004). CONCLUSIONS PPM is associated with high short-term mortality after AVR in China. Female gender, aortic stenosis, bioprosthesis, and high BMI are risk factors for the incidence of PPM.
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Affiliation(s)
- Lei Guo
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Junnan Zheng
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Liangwei Chen
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Renyuan Li
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Liang Ma
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Yiming Ni
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Haige Zhao
- Department of Thoracic and Cardiovascular Surgery, First Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China. .,Department of Cardiothoracic Surgery, the First Affiliated Hospital, Zhejiang University, 79 Qingchun Road, Hangzhou, 310003, China.
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Dayan V, Soca G, Stanham R, Lorenzo A, Ferreiro A. Is patient–prosthesis mismatch a predictor of survival or a surrogate marker of co-morbidities in cardiac surgery? Int J Cardiol 2015; 190:389-92. [DOI: 10.1016/j.ijcard.2015.04.161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/18/2015] [Indexed: 11/15/2022]
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Long-term results of the Medtronic Mosaic porcine bioprosthesis in the aortic position. J Thorac Cardiovasc Surg 2014; 147:1884-91. [DOI: 10.1016/j.jtcvs.2013.07.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 06/21/2013] [Accepted: 07/09/2013] [Indexed: 11/21/2022]
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Bonderman D, Graf A, Kammerlander AA, Kocher A, Laufer G, Lang IM, Mascherbauer J. Factors determining patient-prosthesis mismatch after aortic valve replacement--a prospective cohort study. PLoS One 2013; 8:e81940. [PMID: 24312608 PMCID: PMC3849375 DOI: 10.1371/journal.pone.0081940] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 10/18/2013] [Indexed: 11/25/2022] Open
Abstract
Objective “Patient-prosthesis mismatch” (PPM) after aortic valve replacement (AVR) has been reported to increase morbidity and mortality. Although algorithms have been developed to avoid PPM, factors favouring its occurrence have not been well defined. Design and Setting This was a prospective cohort study performed at the Medical University of Vienna. Patients 361 consecutive patients who underwent aortic valve replacement for isolated severe aortic stenosis were enrolled. Main Outcome Measures Patient- as well as prosthesis-related factors determining the occurrence of moderate and severe PPM (defined as effective orifice area indexed to body surface area ≤ 0.8 cm2/m2) were studied. Results Postoperatively, 172 patients (48%) were diagnosed with PPM. The fact that predominantly female patients were affected (58% with PPM diagnosis in women versus 36% in men, p<0.001) was explained by the finding that they had smaller aortic root diameters (30.5±4.7 mm versus 35.3±4.2 mm, p<0.0001) and a higher proportion of bioprosthetic valves (82% versus 62%, p<0.0001), both independent predictors of PPM (aortic root diameter: OR 0.009 [95% CI, 0.004;0.013]; p = 0.0003, presence of bioprosthetic valve: OR 0.126 [95% CI, 0.078;0.175]; p<0.0001). Conclusions The occurrence of PPM is determined by aortic root diameter and prosthesis type. Novel sutureless bioprostheses with optimized hemodynamic performance or transcatheter aortic valves may become a promising alternative to conventional bioprosthetic valves in the future.
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Affiliation(s)
- Diana Bonderman
- Department of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Alexandra Graf
- Department of Medical Statistics, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Andreas A. Kammerlander
- Department of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Alfred Kocher
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Guenter Laufer
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Irene M. Lang
- Department of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
| | - Julia Mascherbauer
- Department of Cardiology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria
- * E-mail:
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7
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Vernick WJ. Con: patient-prosthesis mismatch now is not an important consideration in the majority of patients after aortic valve replacement. J Cardiothorac Vasc Anesth 2013; 28:184-188. [PMID: 24183317 DOI: 10.1053/j.jvca.2013.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Indexed: 11/11/2022]
Affiliation(s)
- William J Vernick
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA.
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Abstract
Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.
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Blauwet LA, Malouf JF, Connolly HM, Hodge DO, Evans KN, Herges RM, Sundt TM, Miller FA. Comprehensive Echocardiographic Assessment of Normal Mitral Medtronic Hancock II, Medtronic Mosaic, and Carpentier-Edwards Perimount Bioprostheses Early after Implantation. J Am Soc Echocardiogr 2010; 23:656-66. [DOI: 10.1016/j.echo.2010.03.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2009] [Indexed: 11/26/2022]
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10
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Impact of valve prosthesis-patient mismatch estimated by echocardiographic-determined effective orifice area on long-term outcome after aortic valve replacement. Am Heart J 2008; 155:1135-42. [PMID: 18513530 DOI: 10.1016/j.ahj.2007.12.037] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 12/04/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND The impact of valve prosthesis-patient mismatch on long-term outcome after aortic valve replacement estimated by various variables such as projected indexed effective orifice area and internal geometric orifice area obtained from in vivo or in vitro published data is still controversial. METHODS The effective orifice area was measured by echocardiography in 533 patients. The mean age of the patients was 71 +/- 9 years; mean follow-up time was 4.7 +/- 2.2 years. The impact of severe (indexed effective orifice area <or=0.6 cm(2)/m(2)) and moderate mismatch (0.6 cm(2)/m(2) < indexed effective orifice area <or=0.85 cm(2)/m(2)) on survival was evaluated by Cox regression. RESULTS Severe mismatch (hazard ratio: 1.9 [1.08-3.21]) was a significant predictor of survival time after adjustment for age, left ventricular ejection fraction, atrial fibrillation, New York Heart Association class, serum creatinine, and hemoglobin level. The 5- and 7-year survival rates were 71% +/- 4% and 54% +/- 8% for patients with severe mismatch and 83% +/- 4% and 80% +/- 8% for patients with mild mismatch, respectively. The correlation between projected and measured indexed effective orifice area was of medium strength (r = 0.49), and the frequency of observed mismatch depended linearly on the projected indexed effective orifice area. Although projected indexed effective orifice area and indexed internal geometric orifice area were significant predictors of severe mismatch, the sensitivity and specificity for severe prosthesis-patient mismatch were only 75% and 52%, using an optimal threshold of projected indexed effective orifice area defined by the Youden index. CONCLUSIONS Severe prosthesis-patient mismatch estimated by effective orifice area measured within 10 days was an independent risk factor of survival time. Projected indexed effective orifice area determined at surgery does not sufficiently predict mismatch.
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11
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Bajaj M, Abuissa H, Main ML. Rapid bioprosthetic valve degeneration resulting in severe mitral stenosis. J Am Soc Echocardiogr 2007; 21:90.e1. [PMID: 17689922 DOI: 10.1016/j.echo.2007.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2007] [Indexed: 11/28/2022]
Abstract
A 61-year-old man presented 9 months after bioprosthetic mitral valve implantation with progressive exertional dyspnea. Transesophageal echocardiography revealed severe mitral stenosis with diffuse leaflet thickening but no calcification. Subsequent pathologic examination of the valve demonstrated infiltrating fibroconnective tissue and chronic inflammation. Careful echocardiographic follow-up of this valve type may be warranted, especially in patients with early recurrent symptoms.
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Affiliation(s)
- Madhuri Bajaj
- Cardiovascular Consultants and the Mid America Heart Institute, Kansas City, Missouri 64111, USA
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12
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Yap CH, Mohajeri M, Yii M. Prosthesis-Patient Mismatch is Associated with Higher Operative Mortality Following Aortic Valve Replacement. Heart Lung Circ 2007; 16:260-4. [PMID: 17442619 DOI: 10.1016/j.hlc.2007.02.082] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 01/09/2007] [Accepted: 02/05/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Prosthesis-patient mismatch (PPM) occurs when the valve prosthesis implanted at surgery is too small in relation to patient's body size, causing high transvalvular gradients. We investigated if severe PPM is related to early morbidity and mortality after aortic valve replacement (AVR). METHODS We analysed prospectively collected data of 701 consecutive patients undergoing AVR between June 2001 and February 2006 at two Australian public hospitals. The indexed valve effective orifice area (IEOA) was estimated for each valve prosthesis implanted. PPM was defined as <or=0.65 cm2 m(-2). PPM was correlated with operative mortality, stroke, prolonged ventilation, new renal failure, prolonged intensive care stay, prolonged hospital stay and readmission to hospital within 30 days by univariate and multivariate methods. RESULTS PPM was present in 6.6% of patients. Overall operative mortality was 4.1%. Isolated AVR was performed in only 38.4% of patients. For patients with PPM, the univariate and multivariate odds ratio for mortality were 5.2 (P=0.002) and 6.1 (P=0.006), respectively. The other multivariate predictors of mortality were age, pre-operative serum creatinine, emergency status, pulmonary artery pressure and bypass time. PPM was not associated with stroke, prolonged ventilation, new renal failure, prolonged intensive care or hospital stay, or readmission within 30 days. CONCLUSION PPM was associated with increased operative mortality. PPM should be avoided where possible as it may reduce operative mortality following AVR.
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Affiliation(s)
- Cheng-Hon Yap
- Department of Cardiothoracic Surgery, St. Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia.
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Bridges CR, O'Brien SM, Cleveland JC, Savage EB, Gammie JS, Edwards FH, Peterson ED, Grover FL. Association between indices of prosthesis internal orifice size and operative mortality after isolated aortic valve replacement. J Thorac Cardiovasc Surg 2007; 133:1012-21. [PMID: 17382644 DOI: 10.1016/j.jtcvs.2006.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Revised: 11/01/2006] [Accepted: 11/16/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The appropriate index of prosthesis internal orifice size and its effect on operative mortality after aortic valve replacement are controversial. We examined the association between several relevant indices and patient size on operative mortality. Indices examined included projected in vivo effective orifice area and geometric orifice area, with patient size defined as body surface area. METHODS A review of the Society of Thoracic Surgeons National Cardiac Database (2000-2004) yielded 48,722 patients who had isolated aortic valve replacement. This analysis is based on the cohort of 42,310 patients with the 8 most prevalent valve types with manufacturer's labeled sizes 19 mm through 29 mm. Multivariable logistic regression models were employed to determine the effects of body surface area, effective orifice area, geometric orifice area, and selected derived indices (eg, effective orifice area/body surface area) on risk-adjusted operative mortality. RESULTS In separate multivariable models, effective orifice area and geometric orifice area were both inversely correlated with operative mortality. However, an unanticipated finding was that with either effective orifice area or geometric orifice area held constant, body surface area was significantly and inversely correlated with operative mortality. When patients were stratified by effective orifice area, geometric orifice area, or manufacturer's labeled valve size and type, elevations in body surface area were associated with a decrease rather than an increase in operative mortality. CONCLUSIONS Prostheses with small geometric orifice area or small effective orifice area are associated with increased operative mortality after isolated aortic valve replacement. Even for valves with small effective orifice area, however, mortality decreases as body surface area increases. With respect to operative mortality, therefore, our results do not support using arbitrary cutoff values of effective orifice area/body surface area to determine the valve to utilize in a given patient.
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Affiliation(s)
- Charles R Bridges
- Department of Surgery, the University of Pennsylvania Health System, Philadelphia, Pa, USA.
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Raja SG, Macarthur KJ, Pollock JC. Impact of Stentless Aortic Valves on Left Ventricular Function and Hypertrophy: Current Best Available Evidence. J Card Surg 2006; 21:313-9. [PMID: 16684073 DOI: 10.1111/j.1540-8191.2006.00240.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Past four decades have seen a gradual evolution in aortic valve replacement surgery. The ideal valve substitute should combine central flow, low transvalvular gradient, low thrombogenicity, durability, easy availability, resistance to infection, freedom from anticoagulation, and easy implantability. Although there are several types of valves available to replace the diseased aortic valve-autograft, allograft, xenograft, mechanical, and bioprosthetic valves-none is ideal. On one end of the spectrum is the pulmonary autograft, which comes closest to achieving these goals, but creates a double valve procedure for single valve disease, while on the other end are the mechanical valves and stented tissue valves, which allow easy "off the shelf" availability as well as easy implantability but are limited by the potential drawback of causing intrinsic obstruction to some extent because of the space occupied by the stent and sewing ring. Stentless xenograft aortic valves have been developed as a compromise between these ends of the valve spectrum. Stentless aortic valves have been reported to provide more physiologic hemodynamic behavior and cause more timely and thorough regression of ventricular hypertrophy. This review article attempts to evaluate current best available evidence from randomized controlled trials to assess the impact of stentless aortic valves on left ventricular function and hypertrophy.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, UK.
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Moon MR, Pasque MK, Munfakh NA, Melby SJ, Lawton JS, Moazami N, Codd JE, Crabtree TD, Barner HB, Damiano RJ. Prosthesis-Patient Mismatch After Aortic Valve Replacement: Impact of Age and Body Size on Late Survival. Ann Thorac Surg 2006; 81:481-8; discussion 489. [PMID: 16427836 DOI: 10.1016/j.athoracsur.2005.07.084] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Revised: 07/25/2005] [Accepted: 07/26/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to identify patient subgroups in which prosthesis-patient mismatch most influenced late survival. METHODS Over a 12-year period, 1,400 consecutive patients underwent bioprosthetic (933 patients) or mechanical (467) aortic valve replacement. Prosthesis-patient mismatch was defined as prosthetic effective orifice area/body surface area less than 0.75 cm2/m2 and was present with 11% mechanical and 51% bioprosthetic valves. RESULTS With bioprosthetic valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 68% +/- 7% mismatch versus 75% +/- 7% no mismatch, p < 0.02) but not older patients (p = 0.47). Similarly, with mechanical valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 62% +/- 11% versus 79% +/- 4%, p < 0.005) but not older patients (p = 0.26). For small patients (body surface area less than 1.7 m2), prosthesis-patient mismatch did not impact survival with bioprosthetic (p = 0.32) or mechanical (p = 0.71) valves. For average-size patients (body surface area 1.7 to 2.1 m2), prosthesis-patient mismatch was associated with impaired survival with both bioprosthetic (p < 0.05) and mechanical (p < 0.005) valves. For large patients (body surface area greater than 2.1 m2), prosthesis-patient mismatch was associated with impaired survival with mechanical (p < 0.04) but not bioprosthetic (p = 0.40) valves. CONCLUSIONS Prosthesis-patient mismatch had a negative impact on survival for young patients, but its impact on older patients was minimal. In addition, although prosthesis-patient mismatch was not important in small patients, prosthesis-patient mismatch negatively impacted survival for average-size patients and for large patients with mechanical valves.
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Affiliation(s)
- Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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16
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Reagan BW, Kerut EK. Patient-Prosthetic Aortic Valve Mismatch: Role of the Echocardiographer. Echocardiography 2005; 22:365-6. [PMID: 15839996 DOI: 10.1111/j.1540-8175.2005.40015.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Bioprosthetic heart valves have evolved over the years into remarkably useful and predictable devices. During this process, a number of specific designs have come and gone, and a few have remained. Many design changes were successful, and many were not. This article will describe the successes and failures of the various bioprosthetic valve designs and will detail the specific reasons why a particular design change succeeded or failed to improve bioprosthetic valve performance.
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Affiliation(s)
- I Vesely
- Department of Biomedical Engineering/ND20, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Blais C, Dumesnil JG, Baillot R, Simard S, Doyle D, Pibarot P. Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement. Circulation 2003; 108:983-8. [PMID: 12912812 DOI: 10.1161/01.cir.0000085167.67105.32] [Citation(s) in RCA: 368] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The prosthesis used for aortic valve replacement (AVR) can be too small in relation to body size, thus causing valve prosthesis-patient mismatch (PPM) and abnormally high transvalvular pressure gradients. This study examined if there is a relation between PPM and short-term mortality after operation. METHODS AND RESULTS The indexed valve effective orifice area (EOA) was estimated for each type and size of prosthesis being implanted in 1266 consecutive patients and used to define PPM as not clinically significant if >0.85 cm2/m2, as moderate if >0.65 cm2/m2 and <or=0.85 cm2/m2, and as severe if <or=0.65 cm2/m2; it was correlated with 30-day mortality and compared with other relevant variables. Moderate or severe PPM was present in 38% of patients. Thirty-day mortality was 4.6% (58/1266 patients) and the strongest independent predictors in multivariate analysis were left ventricular ejection fraction <40% (P=0.007), infectious endocarditis (P=0.002), emergent/salvage operation (P=0.002), cardiopulmonary bypass time >120 minutes (P=0.001), and PPM (P=0.003). Relative risk of mortality was increased 2.1-fold (95% confidence interval, 1.2 to 3.7) in patients with moderate PPM and 11.4-fold (4.4 to 29.5) in those with severe PPM. Moreover, risk of mortality for every category of PPM was higher in patients with a left ventricular ejection fraction <40% as compared with >or=40% (nonsignificant PPM, 2.7 versus 1.0; moderate PPM, 7.1 versus 1.8; severe PPM, 77.1 versus 11.3). CONCLUSIONS PPM is a strong and independent predictor of short-term mortality among patients undergoing AVR, and its impact is related both to its degree of severity and the status of left ventricular function. In contrast to other risk factors, moderate-severe PPM can be largely avoided with the use of a prospective strategy at the time of operation.
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Affiliation(s)
- Claudia Blais
- Quebec Heart Institute/Laval Hospital, Laval University, Sainte-Foy, Quebec, Canada
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Eichinger WB, Botzenhardt F, Gunzinger R, Kemkes BM, Sosnowski A, Maïza D, Coto EO, Bleese N. European experience with the Mosaic bioprosthesis. J Thorac Cardiovasc Surg 2002; 124:333-9. [PMID: 12167794 DOI: 10.1067/mtc.2002.122552] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to prospectively evaluate the clinical and hemodynamic performance of the Mosaic bioprosthesis (Medtronic, Inc, Minneapolis, Minn). METHODS The stented porcine bioprosthesis combines the amino-oleic acid antimineralization treatment and the zero-pressure differential fixation technique for improved tissue durability. From February 1994 to May 1999, a total of 561 patients underwent valve replacement with the Mosaic bioprosthesis at 5 centers in Europe: 461 in the aortic and 100 in the mitral position. There were 261 women and 300 men; mean age at implantation was 70 years (range, 23-89 years). Mean follow-up was 2.9 years (range, 0-6.2 years), with a total follow-up of 1710.1 patient-years. RESULTS Postoperative mortality was 4.2% per patient-year, including a valve-related mortality of 0.4% per patient-year. The freedom from event rates in the aortic position at 5 years and in the mitral position at 4 years were, respectively, 96.6% +/- 1.1% and 94.9% +/- 3.3% for primary thromboembolism, 96.4% +/- 5.0% and 87.1% +/- 4.8% for antithromboembolic-related hemorrhage, 99.1% +/- 0.5% and 100% for thrombosed prosthesis, 98.8% +/- 1.2% and 100% for structural valve deterioration, 98.8% +/- 0.7% and 100% for nonstructural dysfunction, 98.4% +/- 0.6% and 94.4% +/- 3.8% for endocarditis, and 95.4% +/- 1.6% and 95.3% +/- 3.7% for explant and reoperation. Mean pressure gradient values at 5 years ranged from 7.5 to 15.9 mm Hg in the aortic position and at 4 years from 2.0 to 6.9 mm Hg in the mitral position across all valve sizes. CONCLUSIONS Clinical and hemodynamic performance of the Mosaic bioprosthesis were very satisfactory during the first 6 years after clinical introduction.
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Affiliation(s)
- Walter Benno Eichinger
- Department of Cardiovascular Surgery, Deutsches Herzzentrum Munich, Lazarettstrasse 36, D-80636 Munich, Germany.
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Jamieson WR, Lemieux MD, Sullivan JA, Munro IA, Métras J, Cartier PC. Medtronic Intact porcine bioprosthesis experience to twelve years. Ann Thorac Surg 2001; 71:S278-81. [PMID: 11388204 DOI: 10.1016/s0003-4975(01)02548-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The Medtronic Intact porcine bioprosthesis was further evaluated to determine the influence of zero-pressure glutaraldehyde fixation on structural valve deterioration (SVD). METHODS From 1986 through 1996, at three Canadian centers, 1,272 patients had 1,296 procedures: 836 aortic valve replacement (AVR), 332 mitral valve replacement (MVR), 14 tricuspid valve replacement, 3 pulmonary valve replacement, and 111 multiple valve replacements. The mean age of the patient population was 67 years (range 9 to 91 years). The total follow-up was 8,011 patient-years (mean 6.2 years). RESULTS The late mortality (overall) was 4.8% and 6.7% per patient-year for AVR with or without concomitant procedures, respectively; and 4.7% and 10.4% per patient-year for MVR, respectively. There were 51 cases of SVD (AVR 22 of 836; MVR 23 of 332; pulmonary valve replacement 1 of 3; and multiple valve replacement 5 of 111). The actuarial freedom from SVD at 12 years for AVR was 94.3%+/-3.3% for patients aged 61 to 70 years and 97.7%+/-1.1% for those more than 70 years; for MVR actuarial freedom from SVD at 12 years was 93.7%+/-3.9% for patients more than 70 years. The actual freedom at 12 years from SVD for AVR was 92.4%+/-3.1% for patients aged 51 to 60 years, 96.1%+/-2.1% for those 61 to 70 years, and 98.4%+/-0.7% for those older than 70 years; for MVR actual freedom from SVD at 12 years was 89.6%+/-3.2% for patients 61 to 70 years and 96.6%+/-3.4% for those more than 70 years. CONCLUSIONS The Medtronic Intact porcine bioprosthesis, formulated with tissue preservation at zero-pressure fixation, has encouraging freedom from structural failure.
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Affiliation(s)
- W R Jamieson
- Department of Surgery, University of British Columbia, Vancouver, Canada.
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Thomson DJ, Jamieson WR, Dumesnil JG, Burgess JJ, Peniston CM, Métras J, Sullivan JA, Parrott JC, Maitland A, Cybulsky IJ. Medtronic Mosaic porcine bioprosthesis: midterm investigational trial results. Ann Thorac Surg 2001; 71:S269-72. [PMID: 11388202 DOI: 10.1016/s0003-4975(01)02551-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The midterm clinical and hemodynamic performance of the Medtronic Mosaic porcine bioprosthesis was evaluated in a regulatory trial. METHODS In nine Canadian centers, 802 bioprostheses (560 aortic and 242 mitral) were implanted between September 1994 and April 1999 in patients with a mean age of 70 years. RESULTS Survival for aortic valve replacement at 4 years was 84.4%+/-3.1%. Freedom from valve-related or unexplained death was 95.6%+/-1.9%; structural valve deterioration, 100.0%; reoperation, 96.2%+/-1.7%; major thromboembolism, 96.1%+/-1.8%; and major antithrombotic-related hemorrhage, 96.4%+/-1.7%. Echocardiographic derived mean systolic gradient was 13.4 mm Hg at 4 years with an indexed effective orifice area of 0.7 to 0.8 cm2/m2. A significant decrease in left ventricular mass was shown over time in all valve sizes. Survival for mitral valve replacement at 4 years was 79.2%+/-6.8%. Freedom from valve-related or unexplained death was 96.5%+/-3.4%; structural valve deterioration, 100%; reoperation, 97.0%+/-3.2%; major thromboembolism, 95.7%+/-3.8%; and major antithrombotic-related hemorrhage, 95.0%+/-4.2%. Echocardiographically measured averaged mean diastolic gradient was 4.5 mm Hg. CONCLUSIONS The Medtronic Mosaic bioprosthesis is safe and effective in both the aortic and mitral positions. The valve has low gradients in both positions and excellent left ventricular mass regression in the patients with aortic valve replacement.
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Affiliation(s)
- D J Thomson
- Department of Cardiovascular Surgery, University of Saskatchewan, Saskatoon, Canada.
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Jamieson WR, Janusz MT, MacNab J, Henderson C. Hemodynamic comparison of second- and third-generation stented bioprostheses in aortic valve replacement. Ann Thorac Surg 2001; 71:S282-4. [PMID: 11388205 DOI: 10.1016/s0003-4975(01)02540-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The hemodynamic performance of aortic replacement prostheses is of extreme importance. There is renewed interest in hemodynamics because of the influence of prosthesis-patient mismatch on left ventricular mass regression and the potential influence on survival. METHODS The hemodynamic performance of the second-generation Carpentier-Edwards supraannular porcine and pericardial (Perimount) bioprostheses and the third-generation Medtronic Mosaic porcine bioprosthesis were compared for mean gradient and effective orifice area index. The effective orifice area index of at least 0.85 cm2/M2 was considered as lack of prosthesis-patient mismatch. The study group included included 53 patients with Carpentier-Edwards supraannular porcine, 48 with pericardial, and 98 with Medtronic Mosaic porcine bioprostheses. RESULTS The mean gradients were not different between the prostheses by prosthesis size. The Medtronic Mosaic was not provided in size 19. The mean gradients for the prostheses, except in the very large sizes, were all double-digit values. The effective orifice area index was not different between the prostheses but there was a trend toward prosthesis-patient mismatch in smaller size prostheses. CONCLUSIONS There was no apparent hemodynamic advantage between porcine and pericardial bioprostheses in the aortic position.
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Affiliation(s)
- W R Jamieson
- Department of Surgery, University of British Columbia, Vancouver, Canada.
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Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000; 36:1131-41. [PMID: 11028462 DOI: 10.1016/s0735-1097(00)00859-7] [Citation(s) in RCA: 428] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Prosthesis-patient mismatch is present when the effective orifice area of the inserted prosthetic valve is less than that of a normal human valve. This is a frequent problem in patients undergoing aortic valve replacement, and its main hemodynamic consequence is the generation of high transvalvular gradients through normally functioning prosthetic valves. The purposes of this report are to present an update on the concept of aortic prosthesis-patient mismatch and to review the present knowledge with regard to its impact on hemodynamic status, functional capacity, morbidity and mortality. Also, we propose a simple approach for the prevention and clinical management of this phenomenon because it can be largely avoided if certain simple factors are taken into consideration before the operation.
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Affiliation(s)
- P Pibarot
- Quebec Heart Institute/Laval Hospital, Laval University, Sainte-Foy, Canada
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Wong SP, Legget ME, Greaves SC, Barratt-Boyes BG, Milsom FP, Raudkivi PJ. Early experience with the mosaic bioprosthesis: a new generation porcine valve. Ann Thorac Surg 2000; 69:1846-50. [PMID: 10892935 DOI: 10.1016/s0003-4975(00)01167-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The Mosaic bioprosthesis is a new generation stented porcine valve. METHODS Between May 1995 and April 1998, this valve was implanted in the aortic position in 98 patients (70 men; mean age, 69.2 years [34.2 to 83.6 years]). Preoperatively 35 patients were in New York Heart Association functional class 3 or 4. Fifty-nine patients underwent concomitant procedures. The mean duration at follow-up in January 1999 was 23.7 +/- 10.2 months (0.3 to 39.4 months) and totaled 193 patient-years. All but one survivor was in New York Heart Association class 1 or 2. RESULTS Early complications included 1 death, 3 reoperations for bleeding, greater than mild regurgitation (paravalvar) in 1 patient and thromboembolism in 4 patients. Late complications included four deaths, study-valve endocarditis in 3 patients, more than mild regurgitation or hemolysis in 2, and thromboembolism in 2 patients. Late follow-up echocardiography in all survivors showed a mean transaortic gradient of 13.6 +/- 6.7 mm Hg, and an aortic valve area of 1.80 +/- 0.61 cm2. Valve replacement was followed by a significant and sustained decrease in left ventricular mass for all valve sizes. There has been no primary structural valve failure. CONCLUSIONS The early experience with the Mosaic valve in the aortic position has been promising.
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Affiliation(s)
- S P Wong
- Department of Cardiology, Green Lane Hospital, Auckland, New Zealand
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