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Sá MP, Jacquemyn X, Van den Eynde J, Chu D, Serna‐Gallegos D, Ebels T, Clavel M, Pibarot P, Sultan I. Impact of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data of 122 989 Patients With 592 952 Patient-Years. J Am Heart Assoc 2024; 13:e033176. [PMID: 38533939 PMCID: PMC11179750 DOI: 10.1161/jaha.123.033176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND It remains controversial whether prosthesis-patient mismatch (PPM) impacts long-term outcomes after surgical aortic valve replacement. We aimed to evaluate the association of PPM with mortality, rehospitalizations, and aortic valve reinterventions. METHODS AND RESULTS We performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 2023 (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Sixty-five studies met our eligibility criteria and included 122 989 patients (any PPM: 68 332 patients, 55.6%). At 25 years of follow-up, the survival rates were 11.8% and 20.6% in patients with and without any PPM, respectively (hazard ratio [HR], 1.16 [95% CI, 1.13-1.18], P<0.001). At 20 years of follow-up, the survival rates were 19.5%, 12.1%, and 8.8% in patients with no, moderate, and severe PPM, respectively (moderate versus no PPM: HR, 1.09 [95% CI, 1.06-1.11], P<0.001; severe versus no PPM: HR, 1.29 [95% CI, 1.24-1.35], P<0.001). PPM was associated with higher risk of cardiac death, heart failure-related hospitalizations, and aortic valve reinterventions over time (P<0.001). Statistically significant associations between PPM and worse survival were observed regardless of valve type (bioprosthetic versus mechanical valves), contemporary PPM definitions unadjusted and adjusted for body mass index, and PPM quantification method (in vitro, in vivo, Doppler echocardiography). Our meta-regression analysis revealed that populations with more women tend to have higher HRs for all-cause death associated with PPM. CONCLUSIONS The results of the present study suggest that any degree of PPM is associated with poorer long-term outcomes following surgical aortic valve replacement and provide support for implementation of preventive strategies to avoid PPM after surgical aortic valve replacement.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | | | | | - Danny Chu
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | - Derek Serna‐Gallegos
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - Marie‐Annick Clavel
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Philippe Pibarot
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Ibrahim Sultan
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
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Malvindi PG, Bifulco O, Berretta P, Alfonsi J, Cefarelli M, Zingaro C, Capestro F, D’Alfonso A, Di Eusanio M. Improved Early Outcomes in Women Undergoing Aortic Valve Interventions. J Clin Med 2023; 12:5749. [PMID: 37685816 PMCID: PMC10488507 DOI: 10.3390/jcm12175749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/24/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Surgical aortic valve replacement (SAVR) in female patients has been associated with higher mortality (up to 3.3-8.9%) and postoperative complication rates when compared with their male counterparts. In recent years, TAVI has been shown to provide a greater benefit than SAVR in women. We sought to assess the early outcomes of the contemporary aortic valve intervention practice (surgical and transcatheter) in patients referred to our cardiac surgery unit. The data of consecutive patients who underwent isolated aortic valve intervention for aortic valve stenosis during the 2018-2022 period were retrieved from our internal database. Several preoperative, intraoperative, and postoperative variables were analyzed, including the predicted risk of a prosthesis-patient mismatch. Nine hundred and fifty-five consecutive patients-514 women and 441 men-were included. Among them, 480 patients-276 female and 204 male-received a transcatheter procedure, and 475-238 women and 237 men-had conventional SAVR. The women were older and had higher EuroSCORE II, while the male patients presented a higher incidence of cardiovascular comorbidities. There was no difference in mortality or major postoperative complication rates after either the surgical or transcatheter procedures between the female and male populations. The availability and targeted use of different techniques and technologies have enabled the safe and effective treatment of female patients treated for severe symptomatic aortic valve stenosis with similar results when compared with their male counterparts.
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Dixon LK, Dimagli A, Di Tommaso E, Sinha S, Fudulu DP, Sandhu M, Benedetto U, Angelini GD. Females have an increased risk of short-term mortality after cardiac surgery compared to males: Insights from a national database. J Card Surg 2022; 37:3507-3519. [PMID: 36116056 PMCID: PMC9826035 DOI: 10.1111/jocs.16928] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 06/15/2022] [Accepted: 07/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males. METHODS Using data from National Adult Cardiac Surgery Audit, we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010 to 2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theater for bleeding, and length of hospital stay. Multivariable mixed-effect logistical/linear regression models were used to assess relationships between sex and outcomes, adjusting for baseline characteristics. RESULTS Females, compared to males, had greater odds of experiencing 30-day mortality (CABG odd ratio [OR] 1.76, confidence interval [CI] 1.47-2.09, p < .001; AVR OR 1.59, CI 1.27-1.99, p < .001; MVR OR 1.37, CI 1.09-1.71, p = .006). After CABG, females also had higher rates of postoperative dialysis (OR 1.31, CI 1.12-1.52, p < .001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p = .005) and longer length of hospital stay (β 1.2, CI 1.0-1.4, p < .001) compared to males. Female sex was protective against returning to theater for postoperative bleeding following CABG (OR 0.76, CI 0.65-0.87, p < .001) and AVR (OR 0.72, CI 0.61-0.84, p < .001). CONCLUSION Females in the United Kingdom have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and implementation of strategies to improve outcomes in females.
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Affiliation(s)
| | | | | | - Shubhra Sinha
- Bristol Heart InstituteUniversity of BristolBristolUK
| | | | - Manraj Sandhu
- Bristol Heart InstituteUniversity of BristolBristolUK
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Gupta A, Aliter H, Theriault C, Chedrawy E. Patient-prosthesis mismatch and surgical aortic valve replacement outcomes: Retrospective analysis of single-center surgical data. J Card Surg 2021; 36:2805-2815. [PMID: 34018250 DOI: 10.1111/jocs.15658] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/18/2021] [Accepted: 04/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patient-prosthesis mismatch (PPM) has been identified as a risk factor for mortality and reoperation in patients undergoing surgical aortic valve replacement (SAVR). We present a retrospective analysis of risk factors for PPM and the effects of PPM on early postoperative outcomes after SAVR. METHODS Chart review was conducted for patients (N = 3003) undergoing SAVR. PPM was calculated from valve reference orifice areas and patient body surface area. Logistic regression was used to analyze risk factors for PPM and develop a risk score from these results. Regression was also conducted to identify associations between projected PPM status and postoperative outcomes. RESULTS Risk factors for PPM included female sex, higher body mass index (BMI), and use of the St. Jude Epic valve. Patients receiving St. Jude trifecta valves or mechanical valves were less likely to have predicted PPM. We developed a risk score using BMI, sex, and valve type, and retrospectively predicted PPM in our cohort. Mild PPM (odds ratio [OR] = 2.267), severe PPM (OR = 2.869), male sex (OR = 2.091), and younger age (OR = 0.940) were all predictors of SAVR reoperation, while aortic root replacement was associated with reduced reoperation rates (OR = 0.122). Severe PPM carried a risk of in-hospital mortality (OR = 3.599), and moderate PPM carried a smaller but significant risk (OR = 1.920). Other factors increasing postoperative morbidity and mortality included older age, renal failure, and diabetes. CONCLUSION PPM could be retrospectively predicted in our cohort using a risk calculation from sex, BMI and valve type. We conclude that all degrees of PPM carry risk for mortality and reoperation.
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Affiliation(s)
- Aurinjoy Gupta
- Northern Ontario School of Medicine, Ontario, Thunder Bay, Canada
| | - Hashem Aliter
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Chris Theriault
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Edgar Chedrawy
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Mehaffey JH, Hawkins RB, Wegermann ZK, Grau-Sepulveda MV, Fallon JM, Brennan JM, Thourani VH, Badhwar V, Ailawadi G. Aortic Annular Enlargement in the Elderly: Short and Long-Term Outcomes in the United States. Ann Thorac Surg 2021; 112:1160-1166. [PMID: 33421392 DOI: 10.1016/j.athoracsur.2020.12.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 12/08/2020] [Accepted: 12/21/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patient prosthesis mismatch is associated with significant long-term morbidity and mortality after aortic valve replacement, but the role and outcomes of annular enlargement (AE) remain poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe patient prosthesis mismatch. METHODS Patients over age 65 years undergoing surgical aortic valve replacement with or without coronary artery bypass grafting from 2008-2016 in The Society of Thoracic Surgeons Adult Cardiac Surgery Database with matching Centers for Medicare & Medicaid Services data were included (n=189,268). Univariate, multivariate, and time-to-event analysis was used to evaluate the association between AE and early and late outcomes. Patients were stratified by projected degree of patient prosthesis mismatch based on calculated effective orifice area index. RESULTS A total of 5412 (2.9%) patients underwent AE. The Society of Thoracic Surgeons Adult Cardiac Surgery Database-predicted mortality was similar between AE and non-AE groups (2.97% vs 2.99%, P = .052). Patients undergoing AE had higher risk-adjusted rates of 30-day complications and death (5.4% vs 3.4%, P < .0001), but no differences in long-term rates of stroke, heart failure re-hospitalization,s or aortic valve reoperation. Survival analysis demonstrated a higher risk of mortality with AE during the first 3 years, after which the survival curves cross, favoring AE. CONCLUSIONS These data suggest that annular enlargement during surgical aortic valve replacement is associated with increased short-term risk in a Medicare population. Survival curves crossed after 3 years, which may portend a benefit in select patients. However, annular enlargement is still only performed in the minority of patients who are at risk for patient prosthesis mismatch.
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Affiliation(s)
- J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | | | | | - John M Fallon
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - J Matthew Brennan
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Vinod H Thourani
- Department of Cardiovascular Surgery, Piedmont Heart Institute, Atlanta, Georgia
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
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Dahlbacka S, Laakso T, Kinnunen EM, Moriyama N, Laine M, Virtanen M, Maaranen P, Ahvenvaara T, Tauriainen T, Husso A, Jalava M, Jaakkola J, Airaksinen J, Valtola A, Niemelä M, Mäkikallio T, Eskola M, Vento A, Juvonen T, Biancari F, Raivio P. Patient-Prosthesis Mismatch Worsens Long-Term Survival: Insights From the FinnValve Registry. Ann Thorac Surg 2020; 111:1284-1290. [PMID: 32805269 DOI: 10.1016/j.athoracsur.2020.06.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/22/2020] [Accepted: 06/08/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND The impact of patient-prosthesis mismatch (PPM) on long-term outcome after surgical aortic valve replacement (SAVR) is controversial. We sought to investigate the incidence of PPM and its impact on survival and reinterventions in a Finnish nationwide cohort. METHODS In the context of the nationwide FinnValve registry, we identified 4097 patients who underwent SAVR with a stented bioprosthesis with or without myocardial revascularization. The indexed effective orifice areas (EOAs) of surgical bioprostheses were calculated using literature-derived EOAs. PPM was graded as moderate (EOA 0.65-0.85 cm2/m2) or severe (EOA ≤0.65 cm2/m2). RESULTS The incidence of PPM was 46.0%. PPM was moderate in 38.8% (n = 1579) patients and severe in 7.2% (n = 297) patients. Time-trend analysis showed that the proportion of PPM decreased significantly from 74% in 2009 to 18% in 2017 (P < .01). Severe PPM was associated with increased 5-year all-cause mortality (adjusted hazard ratio [HR], 1.72; 95% confidence interval [CI], 1.07-2.76; P = .02). Severe PPM was not associated with an increased risk of repeat AVR (adjusted HR, 5.90; 95% CI, 0.95-36.5; P = .06). In a subanalysis of patients greater than or equal to 70 years of age, in comparison with no PPM, any PPM (adjusted HR, 1.23; 95% CI, 1.05-1.45; P = .01) and severe PPM (HR, 1.53; 95% CI, 1.17-2.00; P < 0.01) were associated with increased risk of 5-year mortality. CONCLUSIONS Severe PPM after SAVR had a negative impact on survival. This study demonstrated that the effects of PPM should not be overlooked in elderly undergoing SAVR.
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Affiliation(s)
| | - Teemu Laakso
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | | | - Noriaki Moriyama
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Mika Laine
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marko Virtanen
- Heart Hospital, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Pasi Maaranen
- Heart Hospital, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuomas Ahvenvaara
- Department of Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tuomas Tauriainen
- Department of Surgery, Oulu University Hospital, University of Oulu, Oulu, Finland
| | | | - Maina Jalava
- Heart Center, Turku University Hospital University of Turku, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Jussi Jaakkola
- Heart Center, Turku University Hospital University of Turku, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital University of Turku, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland
| | - Antti Valtola
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Matti Niemelä
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Timo Mäkikallio
- Department of Internal Medicine, Oulu University Hospital, Oulu, Finland
| | - Markku Eskola
- Heart Hospital, Tampere University Hospital, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Antti Vento
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland, Finland
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland; Heart Center, Turku University Hospital University of Turku, Turku, Finland; Department of Surgery, University of Turku, Turku, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland, Finland
| | - Peter Raivio
- Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
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Eric Jamieson WR. Commentary: Impact of Prosthesis Size and Prosthesis - Patient Mismatch on Outcomes in Younger Female Patients Undergoing Aortic Valve Replacement. Semin Thorac Cardiovasc Surg 2020; 32:229. [PMID: 32114113 DOI: 10.1053/j.semtcvs.2020.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
Affiliation(s)
- W R Eric Jamieson
- Department of Surgery, University of British Columbia, Academic Director - Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
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