Prosthesis-patient mismatch after transcatheter aortic valve implantation: impact of 2D-transthoracic echocardiography versus 3D-transesophageal echocardiography

Abstract

To investigate the role of 2D-transthoracic echocardiography (2D-TTE) and 3D-transesophageal echocardiography (3D-TEE) in the determination of aortic annulus size prior transcatheter aortic valve implantation (TAVI) and its' impact on the prevalence of patient prosthesis mismatch (PPM). Echocardiography plays an important role in measuring aortic annulus dimension in patients undergoing TAVI. This has great importance since it determines both eligibility for TAVI and selection of prosthesis type and size, and can be potentially important in preventing an inadequate ratio between the prosthetic valvular orifice and the patient's body surface area, concept known as prosthesis-patient mismatch (PPM). A total of 45 patients were studied pre-TAVI: 20 underwent 3D-TEE (men/women 12/8, age 84.8 ± 5.6) and 25 2D-TTE (men/women 9/16, age 84.4 ± 5.4) in order to measure aortic annulus diameter. The presence of PPM was assessed before hospital discharge and after a mean period of 3 months. Moderate PPM was defined as indexed aortic valve area (AVAi) ≤ 0.85 cm(2)/m(2) and severe PPM as AVAi < 0.65 cm(2)/m(2). Immediately post-TAVI, moderate PPM was present in 25 and 28 % of patients worked up using 3D-TEE and 2D-TTE respectively p value = n.s) and severe PPM occurred in 10 % of the patients who underwent 3D-TEE and in 20 % in those with 2D-TTE (p value = n.s). The echocardiographic evaluation 3 months post-TAVI showed 25 % moderate PPM in the 3D-TEE group compared with 24 % in the 2D-TTE group (p value = n.s) and no cases of severe PPM in the 3DTEE group comparing to 20 % in the 2D-TTE group (p = 0.032). Our results indicate a higher incidence of severe PPM in patients who performed 2DTTE compared to those performing 3DTEE prior TAVI. This suggests that the 3D technique should replace the 2DTTE analysis when investigating the aortic annulus diameter in patients undergoing TAVI.

Incidence, Predictors and Outcome of Prosthesis-Patient Mismatch after Transcatheter Aortic Valve Replacement: a Systematic Review and Meta-analysis

“…In our study, we found that MCV had lower incidence of overall and moderate PPM than ESV. Consistently, the pooled results showed that MCV 9 , 12 – 14 , 17 , 18 , 22 , 31 , 33 , 37 had lower mean trans-vavular mean gradient than ESV 9 – 11 , 14 , 16 , 19 – 21 , 23 , 25 , 32 (MCV, 9.3 mmHg vs ESV, 10.2 mmHg, P < 0.001). Additionally, the randomized CHOICE trial 43 also revealed that MCV was associated with lower trans-valvular mean gradient than ESV (MCV vs ESV, 8 mmHg vs 9 mmHg, p = 0.004), albeit no reported data on the comparison of PPM.…”

“…There were 35 studies left after screening the titles and abstracts. After removing overlapping data, a total of 30 studies 9 – 37 incorporating 4,691 patients were eligible. There was 1 study 11 reporting two clusters of patients including randomized and non-randomized clinical trial which was regarded as two independent studies.…”

“…Therefore, an optimized method for measuring annular size was a crucial approach to reducing the occurrence of PPM 39 . Regarding the method of sizing the annulus diameters before TAVR, 3D echocardiography and 3D multidetector CT were superior to 2D echocardiography that could decrease the incidence of PPM 19 , 37 . In addition, Jilaihawi et al .…”

Impact of Prosthesis‐Patient Mismatch on Left Ventricular Myocardial Mechanics After Transcatheter Aortic Valve Replacement

“…In our study, when treatment was divided into 2 periods (2007–2010 and 2011–2013) to reflect the routine use of MDCT or 3D TEE for annular sizing at our institutions from 2011 onward, we detected a 50% reduction in the proportion with PPM during the recent period. Although our data are only hypothesis generating, this may reflect larger‐size prosthesis and better prosthesis selection guided by 3D modalities in the latter period. In our study, no case of PPM occurred with the largest prostheses (Edwards SAPIEN 29 mm or Medtronic CoreValve 29–31 mm), which were typically not available during most studies reporting PPM post‐TAVR.…”

Prosthesis-patient mismatch - what cardiac anesthesiologists need to know?

“…[20] da Silva et al . [21] showed that patients who had 3D TEE measurements of the aortic annulus had a significantly ( P = 0.03) lower incidence of severe PPM after transcatheter AV implantation (TAVI) when compared to those who had annulus measured using 2D TTE (0% with 3D TEE vs. 20% with 2D TTE). While computerized tomography is the most accurate methodology for measuring aortic annulus preoperatively before TAVI, 3D TEE is the most practical method in the operating room for measurement of annular diameter during surgical AVR (SAVR).…”