SHA24/008005

Patient prosthesis mismatch post mitral surgery Antonio Maria CALAFIORE Professor of Cardiac Surgery Director, Department of Adult Cardiac Surgery Prince Sultan Cardiac Center Riyadh Kingdom of Saudi Arabia

Patient-prosthesis mismatch

This concept was introduced

by Rahimtoola in 1978 as a condition in which the in vivo effective orifice area (EOA) of the aortic prosthesis is less than that of native human valve.

Rahimtoola SH et al. The problem of valve prosthesis-patient mismatch.

Circulation 1978;58:20-4.

Patient-prosthesis mismatch

Rahimtoola and Murphy described in 1981 the first prosthesis-patient mismatch in a case of mitral valve replacement (Starr-Edwards, calculated EOA 1.6 cm²).

Rahimtoola SH et al. Valve prosthesis-patient mismatch. A long-term sequela. Br Heart J 1981;45:331-5.

Patient-prosthesis mismatch The EOA is generally provided by manifacturers or inferred by the literature.

Cutpoints are not uniformly accepted, but mismatch can be reasonably defined, in case of MVR,

Patient-prosthesis mismatch The EOA is generally provided by manifacturers or inferred by the literature.

Cutpoints are not uniformly accepted, but mismatch can be reasonably defined, in case of MVR, if indexed EOA (cm²/m²) is ≤1.20, being moderate if iEOA is 0.91-1.20 and severe if ≤0.90.

Patient-prosthesis mismatch 1986-2005: 929 patients had MVR (mech 83.1%)

Magne J et al. Impact of patient-prosthesis mismatch on survival after mitral valve replacement. Circulation 2007;115:1417-25

Patient-prosthesis mismatch 1986-2005: 929 patients had MVR (mech 83.1%) moderate PPM 0.91-1.20 69%

iEOA severe PPM ≤0.90 9% no PPM >1.20 22%

Magne J et al. Impact of patient-prosthesis mismatch on survival after mitral valve replacement. Circulation 2007;115:1417-25

Patient-prosthesis mismatch 1986-2005: 929 patients had MVR (mech 83.1%) moderate PPM 0.91-1.20 69%

iEOA no PPM

severe PPM ≤0.90 9% no PPM >1.20 22%

moderate PPM severe PPM p 0.006

Magne J et al. Impact of patient-prosthesis mismatch on survival after mitral valve replacement. Circulation 2007;115:1417-25

Patient-prosthesis mismatch 1986-2005: 929 patients had MVR (mech 83.1%) moderate PPM 0.91-1.20 69%

iEOA no PPM

severe PPM ≤0.90 9% no PPM >1.20 22%

moderate PPM severe PPM p 0.006

Severe PPM is an independent predictor of mortality after MVR. 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.

Magne J et al. Impact of patient-prosthesis mismatch on survival after mitral valve replacement. Circulation 2007;115:1417-25

Patient-prosthesis mismatch

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch 1985-2005: 884 patients had MVR (mech 74%) PPM = iEOA ≤1.25

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch 1985-2005: 884 patients had MVR (mech 74%) patients with PPM %

57

PPM = iEOA ≤1.25

p<0.001

23

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch 1985-2005: 884 patients had MVR (mech 74%) patients with PPM %

57

p<0.001

PPM = iEOA â&#x2030;¤1.25 survival

p 0.05

23

no PPM PPM

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch 1985-2005: 884 patients had MVR (mech 74%) patients with PPM %

57

p<0.001

PPM = iEOA â&#x2030;¤1.25 survival

p 0.05

23

no PPM PPM

p <0.001

no PPM freedom from recurrent CHF PPM

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch 1985-2005: 884 patients had MVR (mech 74%) patients with PPM %

57

p<0.001

PPM = iEOA â&#x2030;¤1.25 survival

p 0.05

23

no PPM PPM

Predictors of PHTN (>40) older age smaller valve size low EF elevated postop gradients atrial fibrillation use of tissue valve iEOA â&#x2030;¤1.25 did not predict postoperative PHTN

p <0.001

no PPM freedom from recurrent CHF PPM

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch 1985-2005: 884 patients had MVR (mech 74%) patients with PPM %

57

p<0.001

PPM = iEOA â&#x2030;¤1.25 survival

p 0.05

23

no PPM PPM

Predictors of PHTN (>40) older age smaller valve size low EF elevated postop gradients atrial fibrillation use of tissue valve iEOA â&#x2030;¤1.25 did not predict postoperative PHTN

p <0.001

no PPM freedom from recurrent CHF PPM

Patient-prosthesis mismatch after MVR is not uncommon. It is associated with recurrence of CHF and independently affects late survival. PHT was related more to small valve sizes.

Lam B-K et al. The impact of patient-prosthesis mismatch on late outcomes after mitral valve replacement. J Thorac Cardiovasc Surg 2007;133:1464-73

Patient-prosthesis mismatch

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%)

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%) moderate PPM 0.91-1.20 69.5%

iEOA severe PPM â&#x2030;¤0.90 16.4% no PPM >1.20 14.1%

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%) moderate PPM 0.91-1.20 69.5%

iEOA

%

69.5 69.5

severe PPM â&#x2030;¤0.90 16.4% no PPM >1.20 14.1%

tissue mechanical

p=0.670

13.7 14.7

16.8 15.8

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%) overall survival

moderate PPM 0.91-1.20 69.5%

iEOA severe PPM â&#x2030;¤0.90 16.4%

p=0.587

no PPM >1.20 14.1%

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%) overall survival in pts with preop PHTN

moderate PPM 0.91-1.20 69.5%

iEOA severe PPM â&#x2030;¤0.90 16.4%

p=0.085

no PPM >1.20 14.1%

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%) overall survival in pts with preop PHTN

moderate PPM 0.91-1.20 69.5%

iEOA severe PPM â&#x2030;¤0.90 16.4%

p=0.085

no PPM >1.20 14.1%

PPM is not a predictor of overall mortality to 15 years after MVR regardless of the category of effective orifice area index.

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch 1982-2002: 2240 patients had MVR (mech 44.5%) overall survival in pts with preop PHTN

moderate PPM 0.91-1.20 69.5%

iEOA severe PPM â&#x2030;¤0.90 16.4%

p=0.085

no PPM >1.20 14.1%

The preoperative variable, PHT, influences overall mortality in the presence of mild-to-moderate and severe PPM in the survival analysis.

Jamieson WRE et al. Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years. Ann Thorac Surg 2009;87:1135-42

Patient-prosthesis mismatch

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%)

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) iEOA moderate PPM severe PPM â&#x2030;¤0.90 0.91-1.20 14% 37% no PPM >1.20 49%

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) iEOA

%

tissue mechanical

p<0.0001

moderate PPM severe PPM â&#x2030;¤0.90 0.91-1.20 14% 37%

66 45 32 25

no PPM >1.20 49%

30

2

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) iEOA moderate PPM severe PPM ≤0.90 0.91-1.20 14% 37%

patients ≤65 years

no PPM >1.20 49%

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesis–patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) iEOA moderate PPM severe PPM â&#x2030;¤0.90 0.91-1.20 14% 37% no PPM >1.20 49%

patients >65 years

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) tissue valve patients ≤65 years

iEOA moderate PPM severe PPM ≤0.90 0.91-1.20 14% 37% no PPM >1.20 49%

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesis–patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) iEOA moderate PPM severe PPM â&#x2030;¤0.90 0.91-1.20 14% 37%

tissue valve patients >65 years

no PPM >1.20 49%

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 1982-2002: 765 patients had MVR (mech 58%) iEOA moderate PPM severe PPM â&#x2030;¤0.90 0.91-1.20 14% 37%

tissue valve patients >65 years

no PPM >1.20 49%

PPM has a deleterious effect on long term survival in any age. Severe mismatch adversely affected long term survival for older patients receiving bioprosthetic valves.

Aziz A et al. Factors affecting survival after mitral valve replacement in patients with prosthesisâ&#x20AC;&#x201C;patient mismatch. Ann Thorac Surg 2010;90:1202-

Patient-prosthesis mismatch 2001-2009: 1006 patients had MVR (mech 62%) moderate PPM 0.91-1.20 53%

iEOA severe PPM â&#x2030;¤0.90 13% no PPM >1.20 34%

Shi WY et al. Impact of prosthesis-patient mismatch after mitral valve replacement: a multicentre analysis of early outcomes and mid-term survival. Heart 2011;97:1074-81

Patient-prosthesis mismatch 2001-2009: 1006 patients had MVR (mech 62%) PPM according EOA literature moderate PPM 0.91-1.20 53%

iEOA severe PPM â&#x2030;¤0.90 13%

%

tissue mechanical

p<0.0001 51.8 53.5 38.4

no PPM >1.20 34%

26.5

21.7 8.1

PPM

Shi WY et al. Impact of prosthesis-patient mismatch after mitral valve replacement: a multicentre analysis of early outcomes and mid-term survival. Heart 2011;97:1074-81

Patient-prosthesis mismatch 2001-2009: 1006 patients had MVR (mech 62%) moderate PPM 0.91-1.20 53%

iEOA severe PPM â&#x2030;¤0.90 13% no PPM >1.20 34%

Shi WY et al. Impact of prosthesis-patient mismatch after mitral valve replacement: a multicentre analysis of early outcomes and mid-term survival. Heart 2011;97:1074-81

Patient-prosthesis mismatch 2001-2009: 1006 patients had MVR (mech 62%) moderate PPM 0.91-1.20 53%

iEOA severe PPM â&#x2030;¤0.90 13% no PPM >1.20 34%

Overall, PPM was not associated with poorer early outcomes or mid-term survival.

Oversizing valves may be technically hazardous and do not yield superior outcomes.

Shi WY et al. Impact of prosthesis-patient mismatch after mitral valve replacement: a multicentre analysis of early outcomes and mid-term survival. Heart 2011;97:1074-81

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%)

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%)

The analysis was performed on the most frequently implanted sizes (25 to 29)

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%)

The analysis was performed on the most frequently implanted sizes (25 to 29) Mechanical: Tissue:

total

Carbomedics CE pericardial Mosaic

182 135 48

365

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%) PPM according EOA literature % 61.8 31.8 6.4

PPM

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%) PPM according EOA literature %

PPM according EOA literature

61.8

96.1

31.8

%

tissue mechanical

6.4

p<0.0001 59.3

PPM

28.1 12.6 0

3.9

PPM

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%) PPM according EOA literature %

PPM according EOA literature

61.8

96.1

31.8

%

tissue mechanical

6.4

p<0.0001 59.3

PPM

PPM according EOA echo at discharge

12.6 0

84.3

%

28.1 3.9

PPM 13.1 2.6

PPM

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%) PPM according EOA literature %

PPM according EOA echo at discharge

61.8 31.8

%

tissue mechanical

p=ns

88.0 80.5

6.4

PPM

PPM according EOA echo at discharge 4.5 84.3

%

15.0 11.3 0.7

PPM 13.1 2.6

PPM

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVR±TVR/r (mech 49.6%) estimated

PPM according EOA literature

echo p=ns

cm²

% 61.8

p=0.008 p=0.001

2.7

31.8

3.2 3.3

3.0 2.8

2.3 6.4

PPM

PPM according EOA echo at discharge 84.3

%

estimated cm²

p<0.0001

2.5 1.8 13.1 2.6

PPM

m e c h a n i c a l

echo p<0.0001

2.7 2.3

p=ns

2.6 2.5

t i s s u e

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVRÂąTVR/r (mech 49.6%) EOA at discharge was compared with EOA at a follow up of 15Âą4 months in 128 patients (70 mech, 58 tissue)

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVR±TVR/r (mech 49.6%) EOA at discharge was compared with EOA at a follow up of 15±4 months in 128 patients (70 mech, 58 tissue) discharge

follow up

mechanical p=ns

cm²

p=ns p=ns

2.7 2.8

3

3

3.3 3

Department of Adult Cardiac Surgery Prince Sultan Cardiac Center, Riyadh, Saudi Arabia 2008-10: 399 patients had MVR±TVR/r (mech 49.6%) EOA at discharge was compared with EOA at a follow up of 15±4 months in 128 patients (70 mech, 58 tissue) discharge

follow up

discharge

mechanical p=ns

cm²

p=ns p=ns

2.7 2.8

3

3

follow up

tissue

cm²

3.3

p=0.006

3 p=ns

2.5 2.4

2.9

p=0.009

2.9

2.2

2.2

Variability of the EOA: the continuity equation Why is it difficult to have a constant EOA, in particular for tissue valves?

Variability of the EOA: the continuity equation Why is it difficult to have a constant EOA, in particular for tissue valves?

The EOA is obtained using the continuity equation. This involves the stroke volume measured in the left outflow tract and the integral of the mitral valve transprosthetic velocity during diastole.

Variability of the EOA: the continuity equation Why is it difficult to have a constant EOA, in particular for tissue valves?

The EOA is obtained using the continuity equation. This involves the stroke volume measured in the left outflow tract and the integral of the mitral valve transprosthetic velocity during diastole.

Therefore anything affects these two variables will change the EOA accordingly.

Variability of the EOA: the continuity equation Echocardiographic evaluation of EOA at discharge can be misleading because of poor acustic window, hyperdynamic state, flow acceleration in the LV outflow tract (anemia), all elements which overestimate the EOA.

Variability of the EOA: the continuity equation Echocardiographic evaluation of EOA at discharge can be misleading because of poor acustic window, hyperdynamic state, flow acceleration in the LV outflow tract (anemia), all elements which overestimate the EOA. On the other side temporary reduction of LV or RV function can underestimate the EOA, changing both the stroke volume in the LV outflow tract and the velocity of flow across the prosthesis.

Variability of the EOA: the continuity equation Echocardiographic evaluation of EOA after months from the operation can show other problems.

Variability of the EOA: the continuity equation Echocardiographic evaluation of EOA after months from the operation can show other problems.

Reduction of LV or RV function can happen when MR is predominant.

Variability of the EOA: the continuity equation Echocardiographic evaluation of EOA after months from the operation can show other problems.

Reduction of LV or RV function can happen when MR is predominant.

Pulmonary hypertension after MVR for severe MS can persist and, affecting the global cardiac hemodynamics, can influence the EOA as well.

Variability of the EOA: indexing according the BS. And BMI?

Another variable is the indexing of the EOA. The BS is related to the height (constant) and to the weight (variable).

Variability of the EOA: indexing according the BS. And BMI?

Another variable is the indexing of the EOA. The BS is related to the height (constant) and to the weight (variable).

If a patient is overweigthed or frankly obese, his BS increases, but at expences of fat tissue, which is poorly vascularized.

Variability of the EOA: indexing according the BS. And BMI?

Height 1.65 m Weight 112 Kg BS 2.26 m² BMI 41.1

Variability of the EOA: indexing according the BS. And BMI?

Height 1,65 m Height 1.98 m Weight 112 Kg Weight 93 Kg BS 2.26 m² BS 2.26 m² BMI 41.1 BMI 23.7

Variability of the EOA: indexing according the BS. And BMI? Having the same BS, the obese will have some degree of PPM. If we assume that BMI has to be in the upper range of Height 1,65 m Height 1,98 m normalcy (25), his Weight 112 Kg Weight 93 Kg BS now would be BS 2.26 m² BS 2.26 m² BMI 41.1 BMI 23.7 1.76, and, maybe he will have no PPM.

Variability of the EOA: indexing according the BS. And BMI?

This aspect is not negligeable, as, correcting the BS for a BMI in the limit of normalcy (25) will increase the indexed area by about 8-10%.

Variability of the EOA: indexing according the BS. And BMI?

This aspect is not negligeable, as, correcting the BS for a BMI in the limit of normalcy (25) will increase the indexed area by about 8-10%.

In our statistics 40% of the patients had a BMI >25 and 32.8% were obese (BMI>30).

Variability of the EOA: when patients have to be stratified?

When have we to stratify the patients to include them into a precise category (PPM yes, PPM no)?

Variability of the EOA: when patients have to be stratified?

When have we to stratify the patients to include them into a precise category (PPM yes, PPM no)?

We think that stratification has to be done at discharge, even if with the limitation that, anyway, are always present.

Variability of the EOA: when patients have to be stratified?

When have we to stratify the patients to include them into a precise category (PPM yes, PPM no)?

We think that stratification has to be done at discharge, even if with the limitation that, anyway, are always present.

When used for indexing, BS has to be corrected with the BMI. If >25, the weight of the patient has to be the weight he would have if his BMI were 25 (the highest value of normalcy).

Conclusion The definition of PPM is not easy and often the EOA considered (and the relative indexing) is not reliable.

Conclusion The definition of PPM is not easy and often the EOA considered (and the relative indexing) is not reliable.

Prosthesis-patient mismatch is frequent after mitral valve replacement, and varies from 57 to 85.9% in the literature.

In some studies PPM is related to lower survival, but not in others.

Conclusion The problem of PPM in patients with mitral protheses is not well understood.

Conclusion The problem of PPM in patients with mitral protheses is not well understood.

Stratification is not easy, as values obtained from the literature cannot be always applied to every patients.

Conclusion The problem of PPM in patients with mitral protheses is not well understood.

Stratification is not easy, as values obtained from the literature cannot be always applied to every patients.

We have never to forget that EOAs we measure are dependent from variables which can change day by day.