Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch

Castro, Luis J.; Arcidi, Joseph M.; Fisher, Audrey L.; Gaudiani, Vincent A.

doi:10.1016/s0003-4975(02)03680-9

Cited by 134 publications

(87 citation statements)

References 19 publications

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“…5,6,9,16 More importantly, as opposed to other risk factors for cardiac events and mortality, PPM is a modifiable risk factor that can, in large part, be avoided with the use of a prospective strategy at the time of operation. 5,9,16,37 As proposed by Pibarot and Dumesnil,5 this strategy consists of the systematic calculation of the projected EOAi before the implantation of the prosthesis. If the projected EOAi is lower than the recommended value (0.8 to 0.9 cm 2 /m 2 ), the surgeon may either use another type of prosthesis with a better hemodynamic profile and hence a larger EOA (eg, bileaflet mechanical valves of new generation or stentless bioprostheses) 16,38,39 or perform an aortic root enlargement procedure to accommodate a larger prosthesis.…”

Section: Discussionmentioning

confidence: 99%

Impact of Prosthesis-Patient Mismatch on Cardiac Events and Midterm Mortality After Aortic Valve Replacement in Patients With Pure Aortic Stenosis

Tasca

Mhagna²,

Perotti³

et al. 2006

Circulation

200

139

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Background-Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. Methods and Results-The indexed EOA (EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi Յ0.80 cm 2 /m 2 and was correlated with overall mortality and cardiac events. PPM was present in 47% of patients. The 5-year overall survival and cardiac event-free survival were 82Ϯ3% and 75Ϯ4%, respectively, in patients with PPM compared with 93Ϯ3% and 87Ϯ4% in patients with no PPM (PՅ0.01). In multivariate analysis, PPM was associated with a 4.2-fold (95% CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold (95% CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. Conclusions-PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation. (Circulation. 2006;113:570-576.)

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Section: Discussionmentioning

confidence: 99%

Impact of Prosthesis-Patient Mismatch on Cardiac Events and Midterm Mortality After Aortic Valve Replacement in Patients With Pure Aortic Stenosis

Tasca

Mhagna²,

Perotti³

et al. 2006

Circulation

200

139

View full text Add to dashboard Cite

show abstract

“…Moreover, among the risk factors identified to be independently associated with higher postoperative mortality, PPM is the only one that can potentially be avoided by the use of a prospective strategy at the time of operation. Such a strategy has been well described and validated for the prevention of PPM in the aortic position 11,12,26,31 : The projected indexed EOA of the prosthesis to be implanted is calculated, and if PPM is anticipated, potential alternatives include aortic root enlargement to accommodate a larger prosthesis and use of another type of prosthesis with better hemodynamic performance (ie, with a larger EOA).…”

Section: Discussionmentioning

confidence: 99%

Impact of Prosthesis-Patient Mismatch on Survival After Mitral Valve Replacement

et al. 2007

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Background-We recently reported that valve prosthesis-patient mismatch (PPM) is associated with persisting pulmonary hypertension after mitral valve replacement. Thus, the objective of this study was to evaluate the impact of PPM on mortality in patients undergoing mitral valve replacement. Methods and Results-The indexed valve effective orifice area was estimated for each type and size of prosthesis being implanted in 929 consecutive patients and used to define PPM as not clinically significant if Ͼ1.2 cm 2 /m 2 , as moderate if Ͼ0.9 and Յ1.2 cm 2 /m 2 , and as severe if Յ0.9 cm 2 /m 2 . Moderate PPM was present in 69% of patients; severe PPM was seen in 9%. For patients with severe PPM, 6-year survival (74Ϯ5%) and 12-year survival (63Ϯ7%) were significantly less than for patients with moderate PPM (84Ϯ1% and 76Ϯ2%; Pϭ0.027) or nonsignificant PPM (90Ϯ2% and 82Ϯ4%; Pϭ0.002). On multivariate analysis, severe PPM was associated with higher mortality (hazard ratio, 3.2; 95% confidence interval, 1.5 to 6.8; Pϭ0.003). Conclusions-Severe PPM is an independent predictor of mortality after mitral valve replacement. As opposed to other independent risk factors, PPM may be avoided or its severity may be reduced with the use of a prospective strategy at the time of operation. For patients identified as being at risk for severe PPM, every effort should be made to implant a prosthesis with a larger effective orifice area.

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“…Previous studies 10,38,39 have demonstrated that aortic PPM can largely be avoided by systematically calculating the projected indexed EOA of the prosthesis to be inserted (Tables 1 and 2) and, in the case of anticipated PPM, by using alternate procedures such as insertion of a prosthesis model with better hemodynamic performance and aortic root enlargement to accommodate a larger size of the same prosthesis model. Recent studies have reported that this procedure can be performed safely for this purpose, 39 -41 whereas earlier studies showed evidence to the contrary.…”

Section: Prevention Of Ppmmentioning

confidence: 99%

Prosthetic Heart Valves

2009

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Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch

Cited by 134 publications

References 19 publications

Impact of Prosthesis-Patient Mismatch on Cardiac Events and Midterm Mortality After Aortic Valve Replacement in Patients With Pure Aortic Stenosis

Impact of Prosthesis-Patient Mismatch on Cardiac Events and Midterm Mortality After Aortic Valve Replacement in Patients With Pure Aortic Stenosis

Impact of Prosthesis-Patient Mismatch on Survival After Mitral Valve Replacement

Prosthetic Heart Valves

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