Jump to comment:

• PATIENT-PROSTHESIS MISMATCH IN PATIENTS UNDER 70 YEARS OF AGE: DOES IT HAVE AN IMPACT ON SURVIVAL BUT NOT ON VENTRICULAR MASS REGRESSION?
  Rocio Diaz
  Published on: 23 November 2015

• Published on: 23 November 2015

  PATIENT-PROSTHESIS MISMATCH IN PATIENTS UNDER 70 YEARS OF AGE: DOES IT HAVE AN IMPACT ON SURVIVAL BUT NOT ON VENTRICULAR MASS REGRESSION?

  • Rocio Diaz, MD
  • Other Contributors:
    • Rocio Diaz, Daniel Hernandez-Vaquero, Blanca Meana and Cesar Moris.

  Left ventricular (LV) hypertrophy caused by severe aortic stenosis is highly associated with sudden death, congestive heart failure and stroke. After aortic valve replacement (AVR) the pressure gradient between the left ventricle and ascending aorta decreases and reverse left ventricular modeling begins to appear. However, if a certain degree of residual aortic stenosis remains, reverse modeling may be compromised which can affect...

  Show More

  Left ventricular (LV) hypertrophy caused by severe aortic stenosis is highly associated with sudden death, congestive heart failure and stroke. After aortic valve replacement (AVR) the pressure gradient between the left ventricle and ascending aorta decreases and reverse left ventricular modeling begins to appear. However, if a certain degree of residual aortic stenosis remains, reverse modeling may be compromised which can affect clinical outcomes. With great interest, we read the article by Price J and associates1 on the importance of age as a modifier of the relationship between patient-prosthesis mismatch (PPM) and outcomes. Although this article tries to clarify the controversy around this issue, the results are, in absence of an explanation, contradictory in themselves. These conclusions1 may be summarized in: 1. In patients older than 70 years of age, PPM reduced the LV mass index (LVMI) regression in patients with LV dysfunction but not in those with normal LV function. Conversely, PPM had no effect on death or congestive heart failure regardless of LV function. 2. In patients under 70 years of age, PPM did not reduce LVMI regression regardless of LV function. Conversely, PPM was associated with increased death or congestive heart failure in patients with LV dysfunction but not in those with normal LV function. Therefore, it seems that LVMI regression and clinical outcomes are two independent circumstances when intuitively one should cause the other. At this point, we would like to note that, although there are several ways to detect PPM, only two have been considered acceptable in the last years.2 One way is to perform an echocardiography for each patient several months after the intervention. This method has some limitations due to technical difficulties in measurements of echocardiography. Moreover, it is impossible to know if those patients who dye before the echocardiography have mismatch, being precisely these echocardiograms those that could provide more relevant information. Probably due to these limitations, Price J et al.1 opted for the use of tables derived from the literature. However, one must be aware that this method cannot detect all patients with PPM, and there are false-positive and false-negative categorizations.3 Bleiziffer et al.2 demonstrated that the sensitivity and specificity to detect PPM are 71% and 67% when using echocardiographically derived reference tables. Hence, estimations of PPM based on reference tables yield low sensitivity and specificity, leading to incorrect categorization of patients. This effect of false categorization might outweigh that of inaccurate echocardiographic measurements because the effective orifice area of the same prosthesis can vary widely among patients.3 Therefore, so far we have not found the perfect way to detect PPM. This circumstance can explain the contradictory results observed by Price J et al.1 and is probably the main reason why after almost 40 years of research4 we continue to discuss the clinical relevance of a residual aortic stenosis in our postoperative patients. REFERENCES 1. Price J, Toeg H, Lam BK et al. The impact of prosthesis-patient mismatch after aortic valve replacement varies according to age at operation. Heart. 2014;100:1099-106. 2. Bleiziffer S1, Eichinger WB, Hettich I et al. Prediction of valve prosthesis-patient mismatch prior to aortic valve replacement: which is the best method? Heart. 2007;93:615-20. 3. Bleiziffer S, Eichinger WB, Lange R. Letter by Bleiziffer et al regarding article, "Long-term outcomes after valve replacement for low-gradient aortic stenosis: impact of prosthesis-patient mismatch". Circulation. 2006;114:e627. 4. Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation. 1978;58:20-4

  Conflict of Interest:

  None declared

  Show Less

  Conflict of Interest:
  None declared.

  • Back to top