Prosthesis-patient mismatch - what cardiac anesthesiologists need to know?

Aortic root enlargement versus stentless valve implantation for avoidance of patient-prosthesis mismatch in patients with small aortic root: protocol for a systematic review

INTRODUCTION

Avoiding patient-prosthesis mismatch (PPM) in patients with small aortic annulus (SAA) during aortic valve replacement (AVR) is still a challenging surgical problem. Among surgical options available, aortic root enlargement (ARE) and stentless valve implantation (SVI) are the two most commonly used strategies. This systematic review will be conducted searching for superiority evidence based on comparative studies between these two options.

METHODS AND ANALYSIS

This systematic review will include all relevant articles published from 1 January 1946 to 31 March 2024, with available full texts from Medline (Ovid), Embase, Cochrane Library and Web of Science databases, without any language restriction. Observational studies and randomised controlled trials comparing surgical results of ARE versus SVI for AVR in patients with small aortic root will be screened. Studies will be classified into three groups: group 1 for studies that reported SVI or other tissue valve outcomes without comparing them with ARE outcomes; group 2 for studies that reported ARE outcomes without comparing them with SVI outcomes; and group 3 for studies that compared ARE outcomes with SVI outcomes. The quality of the evidence of each study will be evaluated according to Oxford Centre for Evidence-Based Medicine criteria.

ETHICS AND DISSEMINATION

Ethical approval is not required because no primary data are collected. The findings will be presented at scientific conferences and/or reported in a peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

PROSPERO, CRD42023383793.

Comparing clinical and hemodynamic parameters between the two aortic valve replacement in patients with severe aortic stenosis

Context:

Various techniques have been proposed for suturing following prosthetic aortic valve implantation, but each has its potential side effects such as patient-prosthesis mismatch (PPM) and paravalvular leak (PVL).

Aims:

In the present study, we aimed to compare the postoperative sequels of aortic valve replacement (AVR) following the use of two suturing techniques including from the inside of the aorta as the common and classic suturing techniques as compared to new approach including from the outside of the aorta.

Settings and Design:

This cross-sectional study was performed on patients suffering from symptomatic severe aortic valve disease and candidates for AVR in one of three referral hospitals for cardiovascular disease patients in Shiraz from 2019–2021.

Subjects and Methods:

The patients underwent one of the two considered surgical techniques for AVR including traditional approach (n = 60) or the tested approach (suturing from the outside of the aorta) (n = 30).

Statistical Analysis Used:

For statistical analysis, results were presented as mean ± standard deviation for quantitative variables and were summarized by frequency (percentage) for categorical variables.

Results:

PVL and PPM were revealed in none of the participants undergoing the tested approach, while the pointed complications were found in 41.7% and 25.0% of patients underwent traditional approach, respectively, indicating a significant difference. There was no evidence of abnormal dimensionless valve index (DVI) in the patients undergoing sutures from outside the aorta, whereas the rate of DVI abnormality in the patients undergoing traditional procedures was shown to be 18.3%. The mean aortic valve gradient was significantly higher in the group scheduling for the traditional surgical method.

Conclusions:

Applying new suturing method as suturing from the outside of the aorta, due to the selection of appropriate valve size, the risk for adverse consequences including PPM, PVL, or DVI can be significantly reduced.

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.