Prosthesis-Patient Mismatch after Surgical Aortic Valve Replacement: Neither Uncommon nor Harmless.
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ABSTRACT:
SUBMITTER: Rayol SDC
PROVIDER: S-EPMC6629220 | biostudies-literature | 2019 Jun
REPOSITORIES: biostudies-literature
Publications
Prosthesis-Patient Mismatch after Surgical Aortic Valve Replacement: Neither Uncommon nor Harmless.
Rayol Sérgio da Costa SDC Sá Michel Pompeu Barros Oliveira MPBO Cavalcanti Luiz Rafael Pereira LRP Saragiotto Felipe Augusto Santos FAS Diniz Roberto Gouvea Silva RGS Sá Frederico Browne Correia de Araujo E FBCAE Menezes Alexandre Motta AM Silva Frederico Pires Vasconcelos FPV Lima Ricardo Carvalho RC
Brazilian journal of cardiovascular surgery 20190601 3
Prosthesis-patient mismatch (PPM) after surgical aortic valve replacement (SAVR) is an issue that has been overlooked (not to say neglected). Cardiac surgeons must bear in mind that this is a real problem that we must tackle. The purpose of this paper is to be a wake-up call to the surgical community by giving a brief overview of what PPM is, its incidence and impact on the outcomes. We also discuss the increasing role played by imaging for predicting and assessing PPM after SAVR (with which sur ...[more]
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Project description: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 settingThis was a prospective cohort study performed at the Medical University of Vienna.Patients361 consecutive patients who underwent aortic valve replacement for isolated severe aortic stenosis were enrolled.Main outcome measuresPatient- 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 cm(2)/m(2)) were studied.ResultsPostoperatively, 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).ConclusionsThe 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.
| S-EPMC3849375 | biostudies-literature
Project description:BackgroundThe aim of this study was to compare left ventricular (LV) remodeling using myocardial strain between patients with severe aortic stenosis (AS) treated with transcatheter aortic valve replacement (TAVR) with and without prosthesis-patient mismatch (PPM).Methods and resultsIn a retrospective study, speckle-tracking echocardiography was used to measure global longitudinal strain (GLS) and strain rate (GLSR), circumferential strain, and rotation before and at mid-term follow-up post-TAVR. Moderate and severe PPM were defined as an effective orifice area ?0.85 and <0.65 cm(2)/m(2), respectively. A total of 102 patients (median age, 83 years [77-88]) with severe AS were included. At 6±3 months post-TAVR, moderate and severe PPM were found in 32 (31%) and 9 (9%) patients. Patients without PPM had a significant regression in LV mass (from 134±41 to 119±38 g/m(2); P=0.001) at follow-up whereas those with PPM did not. There was a significant improvement in LV GLS (-12.8±4.0 to -14.3±4.3%; P=0.01), GLSR (-0.61±0.20 to -0.73±0.25 second(-1); P<0.001), and early diastolic strain rate (0.52±0.20 to 0.64±0.20 second(-1); P<0.001) in patients without PPM, but not in those with PPM. After adjustment for pre-TAVR ejection fraction and post-TAVR aortic regurgitation, patients without PPM had greater improvement in LV longitudinal strain parameters compared to those with PPM. After a median follow-up of 46.1 months (interquartile range, 35.4-60.8), there was no difference in survival between patients with and without PPM.ConclusionsTAVR was associated with an incidence of PPM of 40%. Greater reverse LV remodeling using myocardial strain was evident in patients without PPM compared to PPM. Presence of PPM was not associated with mortality.
| S-EPMC4802434 | biostudies-literature
Project description:Previous studies of the cost-effectiveness of transcatheter aortic valve replacement (TAVR) have been based primarily on a single balloon-expandable system.The goal of this study was to evaluate the cost-effectiveness of TAVR with a self-expanding prosthesis compared with surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis and high surgical risk.We performed a formal economic analysis on the basis of individual, patient-level data from the CoreValve U.S. High Risk Pivotal Trial. Empirical data regarding survival and quality of life over 2 years, and medical resource use and hospital costs through 12 months were used to project life expectancy, quality-adjusted life expectancy, and lifetime medical costs in order to estimate the incremental cost-effectiveness of TAVR versus SAVR from a U.S.Relative to SAVR, TAVR reduced initial length of stay an average of 4.4 days, decreased the need for rehabilitation services at discharge, and resulted in superior 1-month quality of life. Index admission and projected lifetime costs were higher with TAVR than with SAVR (differences $11,260 and $17,849 per patient, respectively), whereas TAVR was projected to provide a lifetime gain of 0.32 quality-adjusted life-years ([QALY]; 0.41 LY) with 3% discounting. Lifetime incremental cost-effectiveness ratios were $55,090 per QALY gained and $43,114 per LY gained. Sensitivity analyses indicated that a reduction in the initial cost of TAVR by ?$1,650 would lead to an incremental cost-effectiveness ratio <$50,000/QALY gained.In a high-risk clinical trial population, TAVR with a self-expanding prosthesis provided meaningful clinical benefits compared with SAVR, with incremental costs considered acceptable by current U.S.With expected modest reductions in the cost of index TAVR admissions, the value of TAVR compared with SAVR in this patient population would become high. (Safety and Efficacy Study of the Medtronic CoreValve System in the Treatment of Symptomatic Severe Aortic Stenosis in High Risk and Very High Risk Subjects Who Need Aortic Valve Replacement [Medtronic CoreValve U.S. Pivotal Trial]; NCT01240902).
| S-EPMC4959424 | biostudies-literature
Project description:Recently, the use of surgically implanted aortic bioprostheses has been favoured in younger patients. We aimed to analyse the long-term survival and postoperative MACCE (Major Adverse Cardiovascular and Cerebral Event) rates in patients after isolated aortic valve replacement. We conducted a single-centre observational retrospective study, including all consecutive patients with isolated aortic valve replacement. 1:1 propensity score matching of the preoperative baseline characteristics was performed. A total of 2172 patients were enrolled in the study. After propensity score matching the study included 428 patients: 214 biological vs. 214 mechanical prostheses, divided into two subgroups: group A < 60 years and group B > 60 years. The mean follow-up time was 7.6 ± 3.9 years. Estimated survival was 97 ± 1.9% and 89 ± 3.4% at 10 years for biological and mechanical prosthesis, respectively in group A (p = 0.06). In group B the survival at 10 years was 79.1 ± 5.8% and 69.8 ± 4.4% for biological and mechanical prosthesis, respectively (p = 0.83). In group A, patients with a bioprosthesis exhibited a tendency for higher cumulative incidence MACCE rates compared to patients with a mechanical prosthesis, p = 0.83 (bio 7.3 ± 5.3% vs. mech 4.6 ± 2.2% at 10 years). In group B, patients with a mechanical prosthesis showed a tendency for higher cumulative incidence MACCE rates compared to patients with bioprosthesis, p = 0.86 (bio 4.3 ± 3.1% vs. mech 9.1 ± 3.1% at 10 years). Long-term survival after surgical aortic valve replacement is similar in patients with a biological and mechanical prosthesis, independent of the patients' age. Moreover, younger patients (<60 years) with bioprosthesis showed a survival benefit, compared to patients with mechanical prosthesis in this age group.
| S-EPMC8658378 | biostudies-literature
Project description:BackgroundProsthesis-patient mismatch (PPM) following transcatheter aortic valve replacement (TAVR) is common, but the incidence, predictors and outcome of PPM are still controversial.MethodsA total of 18 articles incorporating 72,016 patients were identified form PubMed and Embase online database.ResultsThe pooled incidences of overall, and severe PPM following TAVR were 32.0% and 10.0% separately. Comparing to surgical aortic valve replacement (SAVR), TAVR had lower incidence of overall (OR, 0.31, 95% CI, 0.20-0.50) and severe PPM (OR, 0.38, 95% CI, 0.28-0.52). PPM was associated with a larger body surface area (BSA), larger body mass index (BMI) and previous myocardial infarction in comparison with those patients without PPM. Although PPM was not rare after TAVR, no significant differences were observed both in short- and mid-term all-cause mortality (30 day: OR: 1.51, 95% CI, 0.79-2.87, 1 year: OR: 1.02, 95% CI, 0.96-1.08, and 2 years: OR: 0.99, 95% CI, 0.79-1.24) between patients with PPM and those without PPM.ConclusionsDespite the fact that the incidence of PPM was lower than that of SAVR, PPM was not seen to have an impact on short- and mid-term survival.
| S-EPMC7302587 | biostudies-literature
Project description:BackgroundReoperative aortic valve replacement (AVR) is associated with increased mortality compared with initial surgery, and a smaller valve might be implanted during repeat AVR (re-AVR; AVR after prior AVR). We describe the clinical outcomes and incidence of prosthesis-patient mismatches (PPM) after reoperative AVR.MethodsAmong 113 patients who underwent reoperative AVR between 2007 and 2018, 44 underwent re-AVR and 69 underwent a first replacement of a diseased natural valve after any cardiac surgery except AVR (primary AVR). We then compared early and late outcomes, the impact of re-AVR on the effective orifice areas (EOA), and the incidence and influence of PPM on reoperative AVR.ResultsHospital mortality was 2.7%, and the overall 1-, 3-, and 5-year survival rates were 95, 91 and 86%, respectively. The reference EOA of the newly implanted valve was smaller than that of the previous valve (1.4?±?0.3 vs. 1.6?±?0.3?cm2, p?<?0.01). The mean pressure gradient was greater (15.2?±?6.4 vs. 12.7?±?6.2?mmHg, p?=?0.04) and indexed EOA was smaller (0.92?±?0.26 vs. 1.06?±?0.36?cm2/m2, p?=?0.04) during re-AVR than primary AVR, whereas the incidence of PPM was similar (38.7% vs. 34.8%, p?=?0.87) between the groups.ConclusionsThe clinical outcomes of reoperative AVR were acceptable. Although the reference EOA of new implanted valves was smaller than that of previous valves, re-AVR did not increase the incidence of PPM. These findings might serve as a guide for future decisions regarding the surgical approach to treating degenerated prosthetic valves.
| S-EPMC7104489 | biostudies-literature
Project description:The aim of this study was to investigate the incidence, predictors and outcome of prosthesis-patient mismatch (PPM) following transcatheter aortic valve replacement (TAVR). A total of 30 articles incorporating 4,691 patients were identified. The pooled incidences of overall, moderate and severe PPM following TAVR were 33.0%, 25.0% and 11.0% respectively. Medtronic CoreValve (MCV) had lower incidence of overall (32% vs: 40%, P?<?0.0001) and moderate (23% vs 32%, P?<?0.0001) than Edwards Sapien (ESV). PPM was associated with a younger age, smaller annulus diameter and lower left ventricular ejection fraction in comparison with those patients without PPM. Post-dilation (OR, 0.51, 95% CI, 0.38 to 0.68, p?<?0.001) during TAVR would decrease the incidence of PPM. Although PPM was common after TAVR, no significant differences were observed both in short- and mid-term all-cause mortality (30?day: OR: 1.1, 95% CI, 0.70 to 1.73 and 2 year: OR: 1.01, 95% CI, 0.74 to 1.38) between patients with PPM and those without PPM. In conclusion, despite being common after TAVR, the incidence of PPM was lower than that of surgical aortic valve replacement (SAVR) and decreased with the experience accumulating, and PPM was not seen to impact on short- and mid-term survival, regardless of its magnitude.
| S-EPMC5678180 | biostudies-literature
Project description:PurposeSignificant late-onset tricuspid regurgitation (TR) is unfortunately common after double valve replacement (DVR); however, its underlying factors remain undefined. We evaluated the effect of aortic patient-prosthesis mismatch (PPM) on late-onset TR and clinical outcomes after DVR.Materials and methodsOf the 2392 consecutive patients who underwent aortic valve replacement between January 1990 and May 2014 at our institution, we retrospectively studied 462 patients who underwent DVR (excluding concomitant tricuspid valvular annuloplasty or replacement). Survival and freedom from grade >3 TR were compared between PPM (n=152) and non-PPM (n=310) groups using the Kaplan-Meier method.ResultsAlthough the overall survival rates were similar between the two groups at 5 and 10 years (95%, 91% vs. 96%, 93%, p=0.412), grade >3 TR-free survival was significantly lower in the PPM group (98%, 91% vs. 99%, 95%, p=0.014). Small body-surface area, atrial fibrillation, PPM, and subaortic pannus were risk factors for TR progression. However, aortic prosthesis size and trans-valvular pressure gradient were not significant factors for either TR progression or overall survival.ConclusionAortic PPM in DVR, regardless of mitral prosthesis size, was associated with late TR progression, but was not significantly correlated with overall survival. Therefore, we recommend careful echocardiographic follow-up for the early detection of TR progression in patients with aortic PPM in DVR.
| S-EPMC5552651 | biostudies-literature
Project description:OBJECTIVES More elderly patients (>80 years of age) are being referred for aortic valve replacement (AVR) with or without CABG. Current risk stratification models may not accurately predict the preoperative risk in these patients. We sought to determine which perioperative variables were relevant in determining short-term (30-day to in-hospital) outcomes in our intuition's series of consecutive AVR and AVR+CABG surgeries. We constructed a novel variable, patient-prosthesis mismatch (PPM) in the presence of diminished functional status (NYHA) classification, and studied its role as a predictor of mortality risk. METHODS From 2006 to 2010, 509 patients undergoing AVR or AVR+CABG were evaluated. We created four groups based on the age and procedure (AVR >80, AVR+CABG >80, AVR <80 and AVR+CABG <80). PPM was defined as a calculated effective orifice area index value of ≤ 0.85, and it was calculated from manufacturer-generated charts. In-hospital and 30-day outcomes were assessed using the Chi-square and logistic regression analyses. RESULTS Overall observed 30-day mortality for all groups was lower (n = 8, 1.6%) than the STS-predicted mortality. Reoperation and PPM+NYHA class III-IV were associated with short-term mortality, but age >80 years was not. Octogenarians referred for surgery often had advanced heart failure. CONCLUSIONS Overall, short-term outcomes after AVR with or without CABG were excellent and lower than predicted by the STS model. The low risk of AVR with CABG supports the consideration for earlier surgical referral and intervention for patients with a high likelihood of aortic stenosis progression before the onset of advanced heart failure ensues, regardless of the age. This should help further decrease the already very low mortality observed in these series. Efforts to avoid PPM in the setting of advanced heart failure may improve short-term results in this subset of patients.
| S-EPMC3422943 | biostudies-literature
Project description:Little is known about the incidence of prosthesis-patient mismatch (PPM) and its impact on outcomes after transcatheter aortic valve replacement (TAVR).The objectives of this study were: 1) to compare the incidence of PPM in the TAVR and surgical aortic valve replacement (SAVR) randomized control trial (RCT) arms of the PARTNER (Placement of AoRTic TraNscathetER Valves) I Trial cohort A; and 2) to assess the impact of PPM on regression of left ventricular (LV) hypertrophy and mortality in these 2 arms and in the TAVR nonrandomized continued access (NRCA) registry cohort.The PARTNER Trial cohort A randomized patients 1:1 to TAVR or bioprosthetic SAVR. Postoperative PPM was defined as absent if the indexed effective orifice area (EOA) was >0.85 cm(2)/m(2), moderate if the indexed EOA was ?0.65 but ?0.85 cm(2)/m(2), or severe if the indexed EOA was <0.65 cm(2)/m(2). LV mass regression and mortality were analyzed using the SAVR-RCT (n = 270), TAVR-RCT (n = 304), and TAVR-NRCA (n = 1,637) cohorts.The incidence of PPM was 60.0% (severe: 28.1%) in the SAVR-RCT cohort versus 46.4% (severe: 19.7%) in the TAVR-RCT cohort (p < 0.001) and 43.8% (severe: 13.6%) in the TAVR-NRCA cohort. In patients with an aortic annulus diameter <20 mm, severe PPM developed in 33.7% undergoing SAVR compared with 19.0% undergoing TAVR (p = 0.002). PPM was an independent predictor of less LV mass regression at 1 year in the SAVR-RCT (p = 0.017) and TAVR-NRCA (p = 0.012) cohorts but not in the TAVR-RCT cohort (p = 0.35). Severe PPM was an independent predictor of 2-year mortality in the SAVR-RCT cohort (hazard ratio [HR]: 1.78; p = 0.041) but not in the TAVR-RCT cohort (HR: 0.58; p = 0.11). In the TAVR-NRCA cohort, severe PPM was not a predictor of 1-year mortality in all patients (HR: 1.05; p = 0.60) but did independently predict mortality in the subset of patients with no post-procedural aortic regurgitation (HR: 1.88; p = 0.02).In patients with severe aortic stenosis and high surgical risk, PPM is more frequent and more often severe after SAVR than TAVR. Patients with PPM after SAVR have worse survival and less LV mass regression than those without PPM. Severe PPM also has a significant impact on survival after TAVR in the subset of patients with no post-procedural aortic regurgitation. TAVR may be preferable to SAVR in patients with a small aortic annulus who are susceptible to PPM to avoid its adverse impact on LV mass regression and survival. (The PARTNER Trial: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).
| S-EPMC4237285 | biostudies-literature