Impact of Valve Prosthesis-Patient Mismatch on Long-Term Survival and Left Ventricular Mass Regression After Aortic Valve Replacement for Aortic Stenosis

Long-term valve performance of St Jude Medical Epic porcine bioprosthesis in aortic position

The aim of this study was to review long-term clinical outcomes and valve performance after Epic Supra valve implantation in aortic position. From 2011 to 2022, 44 patients (mean age 75 ± 8 years) underwent surgical aortic valve replacement (SAVR) with an Epic Supra valve at our hospital. Survival, incidence of late complications, and echocardiographic date were retrospectively analyzed. During a mean follow-up period of 6.2 ± 3.5 years, the overall survival rate was 91 ± 4% at 2 and 88 ± 5% at 5 years, while rates of freedom from major adverse cardiovascular and cerebrovascular events (MACCE) were 86 ± 5% and 83 ± 6%, respectively. There was one case of reoperation for prosthetic valve endocarditis at 6 years after the initial surgery. Echocardiographic examinations showed 5-year rates of freedom from severe structural valve deterioration (SVD) and moderate SVD of 100 and 92%, respectively. There was no significant increase in mean pressure gradient or decrease in left ventricular ejection fraction from 1 week after surgery to the late follow-up period. Long-term clinical results and durability of the Epic Supra valve in aortic position were satisfactory.

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

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.

The impact of patient-prosthesis mismatch on early and long-term survival after aortic replacement with the Edwards Perimount valve: A propensity score-matched analysis

BACKGROUND

To investigate the impact of severe patient-prosthesis mismatch (PPM) related to the Edwards Lifesciences Perimount (EP) bioprosthesis in the aortic position on early in-hospital outcomes and long-term survival.

METHODS

A total of 5964 consecutive patients underwent aortic valve replacement at the Bristol Heart Institute between 1998 and 2014, 2667 representing the cohort of this study received EP. PPM was defined severe as EOAi < 0.65 cm² /m² . To minimize bias, propensity score matching was conducted and two groups A and B (without and with severe PPM) of 320 patients with similar preoperative characteristics were matched. We assessed early in-hospital outcomes including CVA, re-exploration for bleeding, low cardiac output, wound infection, acute renal injury, length of hospital stay, and long-term survival for both groups in unmatched and matched populations.

RESULTS

In the unmatched analysis, 18.3% of patients had severe PPM. Severe PPM was not associated with increased in-hospital mortality (4.5% vs. 2.9%, respectively, p = .09) or any other early adverse outcomes except increased length of hospital stay (10.57 ± 8.2 vs. 11.7 ± 9.4, respectively, p = .01). Long-term survival differed significantly between groups at 2 and 8 years (91.8% vs. 91.4% and 60.5% vs. 55.7%, respectively, p = .02). Matched analysis showed no differences between the groups in early health outcomes and overall survival at 2 and 8 years was also similar (89.7% vs. 91% and 57.3% vs. 58%, group A vs. B, respectively p = .9).

CONCLUSION

Presence of PPM does not seem to affect early in-hospital outcomes or late survival when using EP in patients undergoing aortic valve replacement.

Hemodynamics and reverse remodeling associated with Mosaic, Perimount and Trifecta aortic bioprostheses

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.

Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients

Introduction

Patient prosthesis mismatch is known to alter post-operative remodeling of left ventricle adversely in aortic stenosis patients. An indexed orifice area of 0.85 is considered as conventional cutoff for patient prosthesis mismatch based on hemodynamic principles. Many patients have smaller annulus and annulus enlargement techniques may be required to avoid this benchmark which complicates the surgery.

Aims and objectives

To determine incidence of patient prosthesis mismatch (PPM) in our population, to assess left ventricle (LV) regression and impact of indexed effective orifice area on LV regression, and to determine a minimum acceptable cut off indexed orifice area that will result in LV regression.

Materials and methods

A single-center retrospective observational study of all patients who underwent aortic valve replacement surgery for severe aortic stenosis between July 2015 and December 2015 was conducted. Patients who underwent concomitant revascularization or other valve surgery were excluded. Data regarding conventional risk factors for PPM, valve type, and indexed orifice area as well as pre-operative and late post-operative LV mass were collected.

Observations

Thirty-seven of the 91 patients satisfied inclusion criteria. All patients had significant regression in LV mass. The incidence of PPM was 68%. Regression of indexed left ventricular mass showed a positive correlation of with indexed effective orifice area of the prosthetic valve. The correlation coefficient is + 0.48 (95% CI 0.18-0.698). Left ventricular mass regression was significantly higher in patients with indexed effective orifice area more than 0.75 (68.89 ± 29 vs 122.55 ± 58.84, p = 0.028). Relative left ventricular regression also was significantly higher in patients with an indexed effective orifice area more than 0.75 (39.53 ± 13.13 vs 49.73 ± 15.56, p = 0.022). There is a positive correlation between left ventricular regression and the reduction in mean gradient achieved by valve replacement. The correlation coefficient was + 0.35 (95% CI 0.03-0.61).

Conclusions

The incidence of PPM was found to be comparable to literature. There is a positive correlation between left ventricular regression and indexed effective orifice area of the prosthetic valve. Left ventricular regression was significantly higher in patients with an indexed effective area more than 0.75. This can be considered as criteria for significant PPM in study population.

Impact of energy loss index on left ventricular mass regression after aortic valve replacement

Background

Recently, the energy loss index (ELI) has been proposed as a new functional index to assess the severity of aortic stenosis (AS). The aim of this study was to investigate the impact of the ELI on left ventricular mass (LVM) regression in patients after aortic valve replacement (AVR) with mechanical valves.

Methods

A total of 30 patients with severe AS who underwent AVR with mechanical valves was studied. Echocardiography was performed to measure the LVM before AVR (pre-LVM) (n = 30) and repeated 12 months later (post-LVM) (n = 19). The ELI was calculated as [effective orifice area (EOA) × aortic cross sectional area]/(aortic cross sectional area − EOA) divided by the body surface area. The LVM regression rate (%) was calculated as 100 × (post-LVM − pre-LVM)/(pre-LVM). A cardiac event was defined as a composite of cardiac death and heart failure requiring hospitalization.

Results

LVM regressed significantly (245.1 ± 84.3 to 173.4 ± 62.6 g, P < 0.01) at 12 months after AVR. The LVM regression rate negatively correlated with the ELI (R = −0.67, P < 0.01). By receiver operating characteristic (ROC) curve analysis, ELI <1.12 cm²/m² predicted smaller (<−30.0 %) LVM regression rates (area under the curve = 0.825; P = 0.030). Patients with ELI <1.12 cm²/m² had significantly lower cardiac event-free survival.

Conclusion

The ELI as well as the EOA index (EOAI) could predict LVM regression after AVR with mechanical valves. Whether the ELI is a stronger predictor of clinical events than EOAI is still unclear, and further large-scale study is necessary to elucidate the clinical impact of the ELI in patients with AVR.

Can postoperative mean transprosthetic pressure gradient predict survival after aortic valve replacement?

Background

In this study, we sought to determine the effect of the mean transprosthetic pressure gradient (TPG), measured at 6 weeks after aortic valve replacement (AVR) or AVR with coronary artery bypass grafting (CABG) on late all-cause mortality.

Methods

Between January 1998 and March 2012, 2,276 patients (mean age 68 ± 11 years) underwent TPG analysis at 6 weeks after AVR (n = 1,318) or AVR with CABG (n = 958) at a single institution. Mean TPG was 11.6 ± 7.8 mmHg and median TPG 11 mmHg. Based on the TPG, the patients were split into three groups: patients with a low TPG (<10 mmHg), patients with a medium TPG (10–19 mmHg) and patients with a high TPG (≥20 mmHg). Cox proportional-hazard regression analysis was used to determine univariate predictors and multivariate independent predictors of late mortality.

Results

Overall survival for the entire group at 1, 3, 5, and 10 years was 97, 93, 87 and 67 %, respectively. There was no significant difference in long-term survival between patients with a low, medium or high TPG (p = 0.258). Independent predictors of late mortality included age, diabetes, peripheral vascular disease, renal dysfunction, chronic obstructive pulmonary disease, a history of a cerebrovascular accident and cardiopulmonary bypass time. Prosthesis–patient mismatch (PPM), severe PPM and TPG measured at 6 weeks postoperatively were not significantly associated with late mortality.

Conclusions

TPG measured at 6 weeks after AVR or AVR with CABG is not an independent predictor of all-cause late mortality and there is no significant difference in long-term survival between patients with a low, medium or high TPG.

Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement

BACKGROUND

The influence of prosthesis-patient mismatch (PPM) on survival after aortic valve replacement (AVR) remains controversial. In this study, we sought to determine the effect of PPM on early (≤30 days) and late mortality (>30 days) after AVR or AVR combined with coronary artery bypass grafting (AVR with CABG).

METHODS

Between January 1998 and March 2012, 2976 patients underwent AVR (n= 1718) or AVR with CABG (n=1258) at a single institution. PPM was defined as an indexed effective orifice area (EOAI) ≤0.85 cm2/m2 and patients were divided into two groups based on the existence of PPM. Cumulative probability values of survival were estimated with Kaplan-Meier method and compared between groups using Breslow test. Univariate and multivariate independent predictors of early mortality were identified using logistic regression. Cox proportional-hazard regression analysis was used to determine univariate and multivariate independent predictors of late mortality.

RESULTS

Early mortality was 6.7% in the PPM group vs 4.7% in the group with no PPM (p=0.013). Late mortality for the PPM group at 1, 5 and 10 years was 4%, 16% and 43%, respectively. Late mortality for the group with no PPM at 1, 5 and 10 years was 4%, 15% and 33% respectively. Independent predictors of early mortality included age, severely impaired left ventricular (LV) function, endocarditis, renal dysfunction, chronic obstructive pulmonary disease (COPD) and cardiopulmonary bypass (CPB) time. Multivariate independent predictors of late mortality included age, severely impaired LV function, diabetes, peripheral vascular disease (PVD), renal dysfunction, history of a cerebrovascular accident (CVA), CPB time and a history of previous cardiac surgery. PPM was not an independent predictor of early or late mortality.

CONCLUSION

PPM is not an independent predictor of both early and late mortality after AVR or AVR combined with CABG.

Update on aortic valve prosthesis-patient mismatch in Japan

The influence of aortic valve prosthesis-patient mismatch (VP-PM) on the clinical outcome has been an ongoing controversy. The reported prevalence of VP-PM after aortic valve replacement (AVR) ranges widely between 20 and 70 %. The inconsistent impact of VP-PM on short-term and long-term mortality, regression of left ventricular (LV) hypertrophy, and exercise capacity may be explained by differences of the patient populations, the definition of VP-PM, and the use of different prostheses. Moreover, many factors other than the severity of VP-PM should be taken into account when considering its impact on individual patients after AVR. Although the concept of VP-PM is easy to understand, it cannot be applied to the whole patient population. In Japan, the age of the candidates for AVR has increased markedly in recent years, but almost all elderly patients with a small BSA (<1.6 m(2)) have received newer-generation prostheses with a small outer diameter and large effective orifice area. Indeed, previous studies of Japanese patients have demonstrated that VP-PM was no more than moderate in most cases and its impact on clinical outcomes was generally acceptable. Although severe VP-PM is infrequent and its clinical implications are still unproven in elderly Japanese patients, it would seem reasonable to try to prevent severe VP-PM. Thus, VP-PM itself cannot be accepted as an independent risk factor in Japanese patients, but the useful preventive strategies for severe VP-PM in inactive very elderly persons remain controversial. The implantation of newer-generation biological or mechanical prostheses with or without aortic annular enlargement should be considered according to the characteristics of the patient and the risk-benefit ratio for carrying out a particular procedure in an individual patient.

LV reverse remodeling imparted by aortic valve replacement for severe aortic stenosis; is it durable? A cardiovascular MRI study sponsored by the American Heart Association

BACKGROUND

In patients with severe aortic stenosis (AS), long-term data tracking surgically induced effects of afterload reduction on reverse LV remodeling are not available. Echocardiographic data is available short term, but in limited fashion beyond one year. Cardiovascular MRI (CMR) offers the ability to serially track changes in LV metrics with small numbers due to its inherent high spatial resolution and low variability.

HYPOTHESIS

We hypothesize that changes in LV structure and function following aortic valve replacement (AVR) are detectable by CMR and once triggered by AVR, continue for an extended period.

METHODS

Twenty-four patients of which ten (67 ± 12 years, 6 female) with severe, but compensated AS underwent CMR pre-AVR, 6 months, 1 year and up to 4 years post-AVR. 3D LV mass index, volumetrics, LV geometry, and EF were measured.

RESULTS

All patients survived AVR and underwent CMR 4 serial CMR's. LVMI markedly decreased by 6 months (157 ± 42 to 134 ± 32 g/m2, p < 0.005) and continued trending downwards through 4 years (127 ± 32 g/m2). Similarly, EF increased pre to post-AVR (55 ± 22 to 65 ± 11%,(p < 0.05)) and continued trending upwards, remaining stable through years 1-4 (66 ± 11 vs. 65 ± 9%). LVEDVI, initially high pre-AVR, decreased post-AVR (83 ± 30 to 68 ± 11 ml/m2, p < 0.05) trending even lower by year 4 (66 ± 10 ml/m2). LV stroke volume increased rapidly from pre to post-AVR (40 ± 11 to 44 ± 7 ml, p < 0.05) continuing to increase non-significantly through 4 years (49 ± 14 ml) with these LV metrics paralleling improvements in NYHA. However, LVmass/volume, a 3D measure of LV geometry, remained unchanged over 4 years.

CONCLUSION

After initial beneficial effects imparted by AVR in severe AS patients, there are, as expected, marked improvements in LV reverse remodeling. Via CMR, surgically induced benefits to LV structure and function are durable and, unexpectedly express continued, albeit markedly incomplete improvement through 4 years post-AVR concordant with sustained improved clinical status. This supports down-regulation of both mRNA and MMP activity acutely with robust suppression long term.

Aortic valve replacement for aortic stenosis in the elderly: influence of prosthesis-patient mismatch on late survival and left ventricular mass regression

PURPOSE

Controversy still exists about the influence of prosthesis-patient mismatch on outcomes after aortic valve replacement in the elderly. Our aim was to evaluate the effect of prosthesis-patient mismatch on survival and the extent of left ventricular (LV) mass regression after aortic valve replacement for aortic stenosis in Japanese patients aged >or=65 years.

MATERIALS AND METHODS

A total of 84 patients who underwent isolated aortic valve replacement for aortic stenosis between 1986 and 2006 were retrospectively analyzed. Patients were divided into two groups based on the definition of prosthesis-patient mismatch (indexed effective orifice area <or=0.85 cm(2)/m(2)), and long-term results were compared. The mean follow-up time was 4.5 +/- 4.5 years. In 49 patients, follow-up echocardiography was performed at least 6 months after surgery, and the extent of LV mass regression was analyzed according to the presence of a prosthesis-patient mismatch.

RESULTS

Eight years after surgery, there was no significant difference between patients with and without mismatch in terms of actuarial freedom from cardiac-related death (P = 0.159) or death from any valve-related events (P = 0.107). The postoperative transvalvular pressure gradients were not significantly different between the two groups, and significant absolute and relative LV mass regression were observed in both groups.

CONCLUSION

Although a moderate prosthesis-patient mismatch appeared to be tolerable, the criteria of prosthesis-patient mismatch may have to be reassessed for elderly Japanese patients.