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Aortic patient-prosthesis mismatch - does it matter? A review for cardiologists and cardiac surgeons

Alexandru C Visan
Alexandru C Visan
, 
Alexandru Zlibut
Alexandru Zlibut
, 
Adrian Ionescu
Adrian Ionescu
 e 
Serban C Stoica
Serban C Stoica
   | 05 mar 2024
Romanian Journal of Cardiology's Cover Image
INFORMAZIONI SU QUESTO ARTICOLO
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Article Category: Review
Pubblicato online: 05 mar 2024
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DOI: https://doi.org/10.2478/rjc-2024-0001
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© 2024 Alexandru C Visan et al., published by Sciendo
This work is licensed under the Creative Commons Attribution 4.0 International License.

Figure 1

Dimensions of surgical aortic prosthetic valves. (I) Tissue valves. (II) Bileaflet mechanical valves. (A) Overall profile height; (B) outflow tract profile height; (C) internal orifice diameter; (D) internal diameter/internal stent diameter; (E) external stent/housing diameter; (F) external sewing ring diameter. From Durko AP, Head SJ, Pibarot P, et al. Characteristics of surgical prosthetic heart valves and problems around labeling: A document from the European Association for Cardio-Thoracic Surgery (EACTS)—The Society of Thoracic Surgeons (STS)—American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. J Thorac Cardiovasc Surg. 2019;158(4):1041–1054. doi:10.1016/J.JTCVS.2019.04.001. Copyright © 2019 by The Society of Thoracic Surgeons, The American Association for Thoracic Surgery, and the European Association for Cardio-Thoracic Surgery.
Dimensions of surgical aortic prosthetic valves. (I) Tissue valves. (II) Bileaflet mechanical valves. (A) Overall profile height; (B) outflow tract profile height; (C) internal orifice diameter; (D) internal diameter/internal stent diameter; (E) external stent/housing diameter; (F) external sewing ring diameter. From Durko AP, Head SJ, Pibarot P, et al. Characteristics of surgical prosthetic heart valves and problems around labeling: A document from the European Association for Cardio-Thoracic Surgery (EACTS)—The Society of Thoracic Surgeons (STS)—American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. J Thorac Cardiovasc Surg. 2019;158(4):1041–1054. doi:10.1016/J.JTCVS.2019.04.001. Copyright © 2019 by The Society of Thoracic Surgeons, The American Association for Thoracic Surgery, and the European Association for Cardio-Thoracic Surgery.

Figure 2

Relative risk ratio for short-term mortality according to valve prosthesis-patient mismatch and preoperative LV ejection fraction. Numbers above the bars indicate the relative risk ratio for mortality compared with the group with nonsignificant mismatch and normal LV ejection fraction. Reproduced with permission from 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(8):983–988. doi:10.1161/01. CIR.0000085167.67105.32. Copyright © 2003, Wolters Kluwer Health
Relative risk ratio for short-term mortality according to valve prosthesis-patient mismatch and preoperative LV ejection fraction. Numbers above the bars indicate the relative risk ratio for mortality compared with the group with nonsignificant mismatch and normal LV ejection fraction. Reproduced with permission from 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(8):983–988. doi:10.1161/01. CIR.0000085167.67105.32. Copyright © 2003, Wolters Kluwer Health

Figure 3

Moderate and severe PPM was associated with higher perioperative, 1-year, 5-year and 10-year mortality in a large meta-analysis in 2019. Reproduced with permission from Sá MPBDO, De Carvalho MMB, Sobral Filho DC, et al. Surgical aortic valve replacement and patient–prosthesis mismatch: a meta-analysis of 108 182 patients. European Journal of Cardio-Thoracic Surgery. 2019;56(1):44–54. doi:10.1093/EJCTS/EZY466. Copyright © 2019, © The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.
Moderate and severe PPM was associated with higher perioperative, 1-year, 5-year and 10-year mortality in a large meta-analysis in 2019. Reproduced with permission from Sá MPBDO, De Carvalho MMB, Sobral Filho DC, et al. Surgical aortic valve replacement and patient–prosthesis mismatch: a meta-analysis of 108 182 patients. European Journal of Cardio-Thoracic Surgery. 2019;56(1):44–54. doi:10.1093/EJCTS/EZY466. Copyright © 2019, © The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.

Figure 4

A simple algorithm for distinguishing the causes of abnormally high gradients across SAVRs. Reproduced with permission from Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound. Journal of the American Society of Echocardiography. 2009;22(9):975–1014. doi:10.1016/j.echo.2009.07.013. Copyright © 2009, Elsevier.
A simple algorithm for distinguishing the causes of abnormally high gradients across SAVRs. Reproduced with permission from Zoghbi WA, Chambers JB, Dumesnil JG, et al. Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound. Journal of the American Society of Echocardiography. 2009;22(9):975–1014. doi:10.1016/j.echo.2009.07.013. Copyright © 2009, Elsevier.

Figure 5

An example of ‘unavoidable’ PPMM in a large patient with a small LVOT. A: Preoperative measurement of the LVOT diameter in a male undergoing SAVR for severe bicuspid AS, demonstrating a small LVOT (1.9cm). Height 190cm, weight 110kg, BSA 2.41m2. B: Preoperative spectral Doppler interrogation of the AV, demonstrating severe AS (peak velocity 4.6m/s, AVA 0.62cm2).
An example of ‘unavoidable’ PPMM in a large patient with a small LVOT. A: Preoperative measurement of the LVOT diameter in a male undergoing SAVR for severe bicuspid AS, demonstrating a small LVOT (1.9cm). Height 190cm, weight 110kg, BSA 2.41m2. B: Preoperative spectral Doppler interrogation of the AV, demonstrating severe AS (peak velocity 4.6m/s, AVA 0.62cm2).

Figure 6

Examples of biological, both stented and rapid deployment valves, and mechanical valves currently used in aortic valve replacement.
Examples of biological, both stented and rapid deployment valves, and mechanical valves currently used in aortic valve replacement.

Figure 7

Authors’ opinion on the algorithm for the management of the patient presenting with severe aortic stenosis and at risk of patient-prosthesis mismatch (i.e., predicted iEOA ≤0.65cm2/m2 or ≤ 0.55cm2/m2 for obese patients – BMI ≥ 30kg/m2). ARR=Aortic root replacement, ARE=Aortic root enlargement, RDV=Rapid deployment valve, TAVR=Transcatheter Aortic Valve Replacement. †The main absolute contraindications to the Ross operation are described in the section below96. *Other procedures include aortic valve neocuspidization or reconstruction83.
Authors’ opinion on the algorithm for the management of the patient presenting with severe aortic stenosis and at risk of patient-prosthesis mismatch (i.e., predicted iEOA ≤0.65cm2/m2 or ≤ 0.55cm2/m2 for obese patients – BMI ≥ 30kg/m2). ARR=Aortic root replacement, ARE=Aortic root enlargement, RDV=Rapid deployment valve, TAVR=Transcatheter Aortic Valve Replacement. †The main absolute contraindications to the Ross operation are described in the section below96. *Other procedures include aortic valve neocuspidization or reconstruction83.

Figure 8

(A) Main two posterior ARE techniques. With the Manouguian technique (B), the incision is continued through the aortic annulus, at the commissure between the left coronary sinus and the noncoronary sinus and into the aortic-mitral continuity. This can be further extended into the anterior leaflet of the mitral valve to allow a higher degree of enlargement. Care must be taken to preserve the mitral valve leaflet and chordal attachments. With the Nicks technique (C), the aortotomy is continued across the aortic annulus in the nadir of the noncoronary sinus. Reproduced with permission from Grubb KJ. Aortic root enlargement during aortic valve replacement: Nicks and Manouguian techniques. Operative Techniques in Thoracic and Cardiovascular Surgery. 2015;20(3):206–218. doi:10.1053/J.OPTECHSTCVS.2016.02.004100. Copyright © 2016 Elsevier Inc.
(A) Main two posterior ARE techniques. With the Manouguian technique (B), the incision is continued through the aortic annulus, at the commissure between the left coronary sinus and the noncoronary sinus and into the aortic-mitral continuity. This can be further extended into the anterior leaflet of the mitral valve to allow a higher degree of enlargement. Care must be taken to preserve the mitral valve leaflet and chordal attachments. With the Nicks technique (C), the aortotomy is continued across the aortic annulus in the nadir of the noncoronary sinus. Reproduced with permission from Grubb KJ. Aortic root enlargement during aortic valve replacement: Nicks and Manouguian techniques. Operative Techniques in Thoracic and Cardiovascular Surgery. 2015;20(3):206–218. doi:10.1053/J.OPTECHSTCVS.2016.02.004100. Copyright © 2016 Elsevier Inc.

Figure 9

Technical Modifications of the Ross Procedure Aimed at Mitigating Late Autograft Dilatation and Insufficiency. (A) Autologous inclusion technique; (B) Dacron inclusion technique; (C) extra-aortic annuloplasty and interposition graft. Reproduced with permission from Mazine A, El-Hamamsy I, Verma S, et al. Ross procedure in adults for cardiologists and cardiac surgeons. J Am Coll Cardiol. 2018;72(22):2761–2777. doi:10.1016/j.jacc.2018.08.2200. Copyright © 2018 by the American College of Cardiology Foundation. Published by Elsevier.
Technical Modifications of the Ross Procedure Aimed at Mitigating Late Autograft Dilatation and Insufficiency. (A) Autologous inclusion technique; (B) Dacron inclusion technique; (C) extra-aortic annuloplasty and interposition graft. Reproduced with permission from Mazine A, El-Hamamsy I, Verma S, et al. Ross procedure in adults for cardiologists and cardiac surgeons. J Am Coll Cardiol. 2018;72(22):2761–2777. doi:10.1016/j.jacc.2018.08.2200. Copyright © 2018 by the American College of Cardiology Foundation. Published by Elsevier.

Classification of patient-prosthesis mismatch based on severity. Values above represent the effective orifice of area indexed to the BSA (EOAi)

Severity of patient prosthesis-mismatch (based on iEOA)
Mild Moderate Severe
BMI < 30 kg/m2 > 0.85 cm2/m2 0.66 – 0.85 cm2/m2 ≤ 0.65 cm2/m2
BMI ≥ 30 kg/m2 > 0.70 cm2/m2 0.56 – 0.70 cm2/m2 ≤ 0.55 cm2/m2

For any given size label, the actual external diameter of the valve varies according to the model. This is the reason why labelled size cannot be used as a surrogate for LVOT diameter in the continuity equation for calculating the aortic valve area (AVA). From Doenst T, Amorim PA, Al-Alam N, Lehmann S, Mukherjee C, Faerber G. Where is the common sense in aortic valve replacement? A review of hemodynamics and sizing of stented tissue valves. Journal of Thoracic and Cardiovascular Surgery. 2011;142(5):1180–1187. doi:10.1016/j.jtcvs.2011.05.007

Size label Valves External diameter (mm)
Epic Supra Mosaic Perimount Magna Mitroflow
19 – 25 25 26 24 21
21 25 27 27 29 26 24
23 27 29 30 31 28 26
25 29 31 33 33 30 28
27 31 33 36 35 32 32
Sizers
19 – 25 17 19 23 21
21 21 27 18.5 21 25 23
23 23 29 20.5 23 27 26
25 25 31 22.5 25 28.7 28
27 27 33 24 27 31 31

Proportion of patients with severe PPM after SAVR or TAVR, according to stroke volume index. From Abbas AE, Ternacle J, Pibarot P, et al. Impact of flow on prosthesis-patient mismatch following transcatheter and surgical aortic valve replacement. Circ Cardiovasc Imaging. 2021;14(8):E012364. doi:10.1161/CIRCIMAGING.120.012364

SAVR Severe PPM (%)
normal flow 8
low flow 42
TAVR
normal flow 5
low flow 20

Impact of using manufacturer-predicted AVA, rather than continuity-measured, AVA on the prevalence of PPM, in SAVR and TAVR valves. From Ternacle J, Pibarot P, Herrmann HC, et al. Prosthesis-Patient Mismatch After aortic valve replacement in the PARTNER 2 trial and registry. Cardiovascular Interventions. 2021;14(13):1466–1477. doi:10.1016/J.JCIN.2021.03.069

SAVR PPM prevalence (%)
Measured AVA Predicted AVA
Moderate PPM 31 28.4
Severe PPMT 23.6 1.2
TAVR
Moderate PPM 17 21
Severe PPM 0 0.1
eISSN:
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Lingua:
Inglese
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Argomenti della rivista:
Medicine, Clinical Medicine, Internal Medicine, Cardiology, Pediatrics and Juvenile Medicine, Paediatric Cardiology, Surgery, Cardiac Surgery
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