Original article
Adult cardiac
Effect of Prosthesis-Patient Mismatch on Long-Term Survival With Aortic Valve Replacement: Assessment to 15 Years

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
https://doi.org/10.1016/j.athoracsur.2009.08.070Get rights and content

Background

The effect of prosthesis-patient mismatch on long-term survival after aortic valve replacement has received considerable attention but there remains controversy. This study was performed to determine the predictors of mortality after aortic valve replacement and influence of prosthesis-patient mismatch on survival.

Methods

Contemporary mechanical prostheses and bioprostheses were implanted in 3,343 patients with aortic valve replacement between 1982 and 2003. The mean age was 68.06 ± 11.20 years (median 70.06; range, 19 to 94), and the mean follow-up was 6.18 ± 4.96 years, for a total of 20,666 years of follow-up. Prosthesis-patient mismatch was classified by effective orifice area index categories: normal (>0.85 cm2/m2), 1,547 (46.3%); mild-to-moderate (>0.65 cm2/m2 to ≤0.85 cm2/m2), 1,584 (47.4%); and severe (<0.65 cm2/m2), 212 (6.3%).

Results

The predictors of overall mortality were age, age categorization, New York Heart Association functional class III/IV, concomitant coronary artery bypass graft surgery, prosthesis type, preoperative congestive heart failure, diabetes mellitus, renal failure, and chronic obstructive pulmonary disease. All categories of effective orifice area indexes were not predictive of overall mortality, late mortality, or early mortality. The 15-year overall survival was differentiated by effective orifice area index categories: 38.1% ± 2.1%, 37.0% ± 2.2%, and 22.1% ± 6.5%, respectively, for the three categories. Survival adjusted for the covariates (effective orifice area index, age, basal mass index, and ejection fraction) determined no effect except severe effective orifice area index when adjusted for ejection fraction more than 50% (p = 0.049).

Conclusions

Prosthesis-patient mismatch is not a predictor of overall standard unadjusted mortality to 15 years after aortic valve replacement, regardless of the category of effective orifice area index.

Section snippets

Patients and Methods

This is a retrospective study of prospectively collected data from the University of British Columbia Cardiac Valve Database. The database receives annual renewal from the University of British Columbia Clinical Research Ethics Board, which has a formal informed consenting process of patients.

From 1982 to 2003, 3,343 patients had aortic valve replacements at the affiliated teaching hospitals (St. Paul's Hospital, Vancouver General Hospital, and Royal Columbian Hospital) of the University of

Results

Of the total population of 3,343 patients, 1,547 (46.3%) had nonsignificant PPM, 1,584 (47.4%) had mild-to-moderate PPM, and 212 (6.3%) had severe PPM. The mean follow-up was 6.2 ± 5.0 years. During follow-up, 1,050 (31.4%) died: early mortality, 114 (3.4% [BP 4.0% (99), MP 1.8% (15)]; p = 0.002); late mortality, 1,050 (31.8%); cardiac-related mortality, 419 (12.5%); and valve-related mortality, 190 (5.7%). The early mortality for nonsignificant/normal PPM patients (PPM group A) was 3.4% (52);

Comment

The considered opinion of the hemodynamic consequence of prosthesis-patient mismatch is increased transvalvular gradients after aortic valve replacement and delay of regression of left ventricular hypertrophy and predictor of survival. There is considerable evidence that severe and (possibly) moderate PPM has a detrimental influence on early and late mortality [2, 3, 4, 5, 6, 7, 8].

The predominant investigators in the area of prosthesis-patient mismatch have been Pibarot and Dumesnil, with

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