Impact of Prosthesis-Patient Mismatch on Long-Term Survival in Patients With Small St Jude Medical Mechanical Prostheses in the Aortic Position

Abstract

Background-The impact of aortic prosthesis-patient mismatch (P-PtM) on long-term survival is unclear. . P-PtM was severe in 66 patients (17%), moderate in 168 (43%), and not hemodynamically significant in 154 (40%). Patients with severe P-PtM had a significantly larger body surface area (PϽ0.0001), higher mean gradient (PϽ0.0001), lower preoperative (PϽ0.0001) and postoperative (PϽ0.0001) ejection fractions, and lower stroke volume (PϽ0.0001) and more often received a 19-mm prosthesis (Pϭ0.0008) than patients with moderate or no hemodynamically significant mismatch. For patients with severe mismatch, 5-year survival rates (72Ϯ6%) and 8-year survival rates (41Ϯ8%) were significantly less than for patients with moderate mismatch (80Ϯ3% and 65Ϯ5%; Pϭ0.026) or no hemodynamically significant mismatch (85Ϯ3% and 74Ϯ5%; Pϭ0.002). On multivariate analysis after adjustment for other predictors of outcome, severe mismatch was associated with higher mortality (hazard ratio 2.18; 95% confidence interval 1.24 to 3.85; Pϭ0.007) and higher incidence of congestive heart failure (hazard ratio 3.1; 95% confidence interval 1.3 to 7.4; Pϭ0.009) than no hemodynamically significant mismatch. Conclusions-Severe P-PtM is an independent predictor of higher long-term mortality and congestive heart failure in patients with small St Jude Medical aortic valve prostheses. For patients undergoing AVR who are at risk of severe mismatch, every effort should be made to use a larger prosthesis or to consider a prosthesis with a larger EOA. Methods and Results-Between

Long-Term Clinical and Echocardiographic Follow-Up of the Freestyle Stentless Aortic Bioprosthesis

“…When evaluating patients with small size St Jude prostheses, the Mayo Clinic group found only patients with severe mismatch (IEOA Ͻ0.65 cm 2 /m 2 ) to be at increased risk for long-term mortality and recurrent congestive heart failure. 36 PPM did not impact all-cause mortality in their study. On the other hand, the Cleveland Clinic group showed similar functional recovery after AVR in all of the patients, even in the presence of severe PPM.…”

Defining the Efficacy of Aortic Root Enlargement Procedures: A Comparative Analysis of Surgical Techniques

“…Furthermore, there is evidence to suggest that certain ARE procedures may be inadequate and leave patients with residual severe PPM 14 ; signifying that perhaps the most appropriate techniques are not always being chosen. Therefore, the objective of this study was to provide comparative data to clarify the current beliefs concerning the upsizing of aortic valve prostheses attainable with the Nicks, Manougian, modified Bentall, and aortoventriculoplasty procedures.…”

Midterm outcome after aortic root replacement with stentless porcine bioprostheses☆☆☆

“…There is an ongoing debate whether prosthesis-patient mismatch has a clinical impact or not [2]. However, recent studies relying on effective orifice areas actually measured by echocardiography in each single patient, instead of the calculated areas obtained from manufacturers or the literature, showed a reduced survival for patients with prosthesis-patient mismatch [3,4].…”