Impact of Valve Prosthesis-Patient Mismatch on Left Ventricular Mass Regression Following Aortic Valve Replacement

doi:10.1016/j.athoracsur.2004.04.042

The Annals of Thoracic Surgery

Volume 79, Issue 2, February 2005, Pages 505-510

https://doi.org/10.1016/j.athoracsur.2004.04.042 Get rights and content

Abstract

Background

Valve prosthesis-patient mismatch is a frequent problem in patients undergoing aortic valve replacement and its main hemodynamic consequence is to generate high transvalvular gradients through normally functioning prosthetic valves. The persistence of high gradients may hinder or delay the regression of left ventricular hypertrophy after aortic valve replacement.

Methods

The aim of the study was to determine the impact of prosthesis-patient mismatch on the postoperative regression of left ventricular mass.

Left ventricular mass was measured by Doppler echocardiography in 109 patients undergoing aortic valve replacement with a single type of bioprosthesis (Carpentier-Edwards Perimount) for pure aortic stenosis. Prosthesis-patient mismatch was defined as a projected indexed effective orifice area less than 0.90 cm²/m². On this basis, 58/109 (53.2%) patients had prosthesis-patient mismatch.

Results

There was a good correlation (r = 0.61, p < 0.001) between the postoperative mean transprosthetic gradient and the projected indexed effective orifice area. The absolute and relative left ventricular mass regression was significantly (p = 0.002 and p = 0.01, respectively) lower in patients with prosthesis-patient mismatch (−48 ± 47 g, −17% ± 16%) compared to those with no prosthesis-patient mismatch (−77 ± 49 g, −24% ± 14%). In multivariate analysis, a larger projected indexed effective orifice area, female gender and a higher preoperative left ventricular mass are independent predictors of greater left ventricular mass regression.

Conclusions

This study shows that in patients with pure aortic stenosis prosthesis-patient mismatch is associated with lesser regression of left ventricular hypertrophy after aortic valve replacement. These findings may have important clinical implications given that prosthesis-patient mismatch is frequent in these patients.

Section snippets

Patients and Methods

The study population includes 109 patients with pure aortic stenosis (AS) who underwent AVR between September 1997 and July 2002. All patients received a Carpentier-Edwards Perimount (CEP) bioprosthesis (Edwards Lifesciences, Irvine, CA). The distribution of patients in regards to prosthesis size was: 19 mm: 38 patients (34.8%), 21 mm: 39 patients (35.8%), 23 mm: 29 patients (26.6%), 25 mm: 3 patients (2.7%).

The patients with more than mild aortic regurgitation, previous myocardial infarction,

Preoperative and Operative Data

The patients' preoperative and operative characteristics are shown in Table 1. Patients with PPM and those with no PPM were similar in respect to these data except for gender distribution, body mass index, and aortic valve pressure gradients. The prevalence of LV hypertrophy before operation was more than 90% in both groups. Patients with PPM had a higher proportion of smaller prostheses as shown in Figure 1. However, it should be noted that a significant proportion of patients with a small (≤

Comment

As in previous studies 11, 12, 19, 20, 21, gender and preoperative LV mass have also been identified as independent predictors of LV mass regression in the present study. It is well known that there is a gender-related difference in the behavior of pressure overload-induced LV hypertrophy, with males developing a greater mass, less concentric hypertrophy, more systolic stress and a lower LV ejection fraction [22]. As reported in other studies 23, 24, 25, regression of LV hypertrophy was not

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This review summarizes sex-based differences in aortic stenosis (AS) and identifies knowledge gaps that should be addressed by future studies.
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There is sex difference in clinical presentation and anatomical characteristics, with women having more paradoxical low-flow/low-gradient AS, under-diagnosis and severity underestimated, with less referral to aortic valve replacement (AVR) compared to men. The response to therapies is also different: women have more adverse events with surgical AVR and greater survival benefit with transcatheter AVR. After AVR, women would have more favorable LV remodeling, but sex-related differences in changes in myocardial reserve flow need future research.
Investigation into these described sex-related differences in AS offers potential utility for improving prevention and treatment of AS in women and men. To better understand sex-based differences in pathophysiology, clinical presentation, and response to therapies, sex-specific critical knowledge gaps should be addressed in future research for sex-specific personalized medicine.
Aortic Valve Neocuspidization Using Xenologous Pericardium Versus Bioprosthetic Valve Replacement
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Surgical aortic valve replacement (SAVR) for patients with aortic valve stenosis (AS) with small aortic root is associated with a higher rate of prosthesis–patient mismatch and suboptimal clinical outcomes. Aortic valve neocuspidization using xenologous pericardium (xAVNeo) has shown a favorable hemodynamic performance. The aim was to compare 6-year clinical outcomes of xAVNeo with SAVR.
Between 2003 and 2018, 412 patients with severe AS and small aortic root received either xAVNeo (n = 114) or bioprosthesis (n = 298). After propensity matching the cohort included 222 patients. The primary endpoints were early mortality, 6-year mortality, and freedom from reoperation. Mean follow-up averaged 3.4 ± 3.1 years and was 95% complete.
Early mortality was 8.1% for the SAVR group versus 9.9% for the xAVNeo group (odds ratio, 1.25; 95% confidence interval, 0.51-2.89). The estimated survival probabilities at 6 years for the SAVR and xAVNeo cohorts were 89.9% and 88.8%, respectively (odds ratio, 1.07; 95% confidence interval, 0.49-2.34). Progressive degeneration of the neocusps resulted in a mean gradient increase from 6.1 ± 2.3 mm Hg to 22.7 ± 11.5 mm Hg (P < .0001); cusp sclerosis was the most common indication for reoperation in the xAVNeo group with a linearized rate of 1.92% versus 0.26% per patient-year (rate ratio, 7.41; 95% confidence interval, 0.95-333.7). The freedom from reoperation was 84.8% at 6 years, inferior to that of the SAVR group (100%).
Early clinical outcomes and 6-year survival rates after xAVNeo and SAVR were comparable. However xAVNeo using bovine pericardium was associated with a higher rate of structural valve deterioration and inferior freedom from reoperation when compared with SAVR.
Men are from mars, women are from venus: Factors responsible for gender differences in outcomes after surgical and trans-catheter aortic valve replacement
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Females suffer higher operative (30-day) mortality than males after surgical aortic valve replacement (SAVR). In contrast, outcomes after trans-catheter aortic valve replacement (TAVR) seem to favor females, both in terms of procedural mortality, and more prominently, medium to long-term survival. With an ever-greater number of TAVR procedures being performed, an understanding of factors responsible for gender differences in outcomes after the two AVR modalities is critical for better patient selection. Current evidence suggests that this gender difference in outcomes after SAVR and TAVR stems from differences in baseline risk profiles, as well as inherent anatomic/physiological differences between genders. This review attempts to examine these clinical and physiological factors, with a goal of guiding better patient selection for each AVR modality, and to highlight areas that beg further investigation.
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The safety and efficacy of aortic root enlargement (ARE) at the time of aortic valve replacement (AVR) remains unknown. The objective of this multicenter study was to compare AVR with ARE to AVR for early and late mortality and secondary safety outcomes.
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Sixteen thousand six hundred fifty-six patients undergoing AVR in 11 Ontario institutions were reviewed. Patients who underwent ARE were younger, nonurgent, more likely to be men and had lower rates of hypertension, ischemic heart disease, and congestive heart failure. Propensity score matching yielded similar groups for comparison, with 809 pairs for AVR versus AVR with ARE. There was no difference in 30-day mortality between AVR with ARE versus AVR (2.0% vs 2.1%; P = 1.00). Rates of chest reopening for bleeding, permanent pacemaker implantation, and blood transfusions were similar. Late mortality over 8 years was similar between AVR with ARE and AVR (P = .45). In a sensitivity analysis, results were similar in 525 pairs comparing AVR with coronary artery bypass grafting and ARE to AVR with coronary artery bypass grafting, except that chest reopening for bleeding was higher with AVR with coronary artery bypass grafting and ARE (7.2% vs 3.2%; P = .006).
The addition of ARE to isolated AVR can be safely performed to increase implanted prosthesis size without compromising early mortality. Additional studies with longer follow-up are necessary.
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This study sought to compare the frequency of prosthesis-patient mismatch (PPM) with self-expandable valves (SEV) to balloon-expandable valves (BEV).
PPM has been associated with increased mortality after transcatheter aortic valve replacement. Data on the frequency of PPM as a function of supra-annular or intra-annular position of transcatheter heart valves are insufficient.
A total of 757 patients treated with SEV (CoreValve, Evolut R) and BEV (SAPIEN THV/XT/3) were enrolled in the present analysis between August 2007 and June 2017. PPM was classified based on discharge prosthetic effective orifice area indexed to body surface area (BSA) as severe (<0.65 cm²/m²) or moderate (0.65 to 0.85 cm²/m²) in the general population, and as severe (<0.60 cm²/m²) or moderate (0.60 to 0.90 cm²/m²) in the obese population (body mass index ≥30 kg/m²).
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Original article: CardiovascularImpact of Valve Prosthesis-Patient Mismatch on Left Ventricular Mass Regression Following Aortic Valve Replacement

Abstract

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Preoperative and Operative Data

Comment

Am J Med Sci

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Coll Cardiol

Ann Thorac Surg

Am J Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Int J Cardiol

Am Heart J

Left ventricular hypertrophy and geometric remodeling in hypertensionstimuli, functional consequences and prognostic implications

J Hypertension

Prognostic implications of echocardiographically determined left ventricular mass in the framingham heart study

N Engl J Med

Original article: Cardiovascular
Impact of Valve Prosthesis-Patient Mismatch on Left Ventricular Mass Regression Following Aortic Valve Replacement