Prosthesis-patient mismatch in the mitral position: old concept, new evidences

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Impact of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation

Negative impact of prosthesis-patient mismatch on long-term survival after valve replacement has been reported. However, the effect of prosthesis-patient mismatch after bioprosthetic mitral valve replacement has not yet been well examined. The purpose of this study was to investigate the effect of prosthesis-patient mismatch on late outcomes after bioprosthetic mitral valve replacement for mitral regurgitation. A total of 181 patients underwent bioprosthetic mitral valve replacement between April 2008 and December 2016. After excluding patients with mitral stenosis and those with incomplete data, 128 patients were included in the study. Postoperative transthoracic echocardiography was performed before discharge for all patients and the effective orifice area of bioprosthetic mitral valve was calculated using the formula: 220/pressure half-time, and the effective orifice area index was calculated by the formula: effective orifice area/body surface area. Prosthesis-patient mismatch was defined as a postoperative effective orifice area index ≤ 1.2 cm²/m². The characteristics and outcomes were compared between the groups. There were 34 patients (26.6%) with prosthesis-patient mismatch and 94 patients (73.4%) without prosthesis-patient mismatch. There were no significant differences in the in-hospital mortality and morbidities. Multivariable analysis showed that prosthesis-patient mismatch was an independent predictor of late mortality (hazard ratio 3.38; 95% confidence interval 1.69-6.75; p = 0.001) and death from heart failure (hazard ratio 31.03, 95% confidence interval 4.49-214.40, p < 0.001). Prosthesis-patient mismatch at discharge after mitral valve replacement for mitral regurgitation was associated with long-term mortality and death from heart failure.

Incidence and predictors of mismatch after mechanical mitral valve replacement

Background

Patient-prosthesis mismatch after mitral valve replacement has an unfavorable postoperative hemodynamic outcome, which underlines the importance of identifying and preventing prosthesis- and patient-related risk factors. This study was conducted to determine the incidence and identify possible predictors of patient-prosthesis mismatch.

Methods

A prospective study was conducted on 715 patients with a mean age of 42 ± 11 years who underwent mechanical mitral valve replacement between 2013 and 2017. The effective orifice area of the prostheses was estimated by the continuity equation, and a mismatch was defined as an effective orifice area index ≤1.2 cm2·m−2. The mean clinical and echocardiographic follow-up was 26.74 ± 11.58 months. Multivariate regression analysis was performed to identify predictors of patient-prosthesis mismatch.

Results

Patient-prosthesis mismatch was detected in 382 (53.4%) patients. A small mechanical prosthesis (<27 mm) was inserted in 54.3%. Mortality during follow-up was 9% (65 patients). Patient-prosthesis mismatch was identified in patients with preoperative rheumatic mitral valve pathology, associated tricuspid regurgitation, higher New York Heart Association class, preoperative atrial fibrillation, mitral stenosis, and small preoperative left ventricular dimensions. Multivariate analysis identified mitral stenosis, preoperative atrial fibrillation, and small postoperative left ventricular end-diastolic dimension as risk factors for patient-prosthesis mismatch.

Conclusion

Patient-prosthesis mismatch is a common sequela after mechanical mitral valve replacement. Identification of predictors of patient-prosthesis mismatch can help so that a preoperative strategy can be implemented to avoid its occurrence.

Prosthetic valves in adult patients with congenital heart disease: Rationale and design of the Dutch PROSTAVA study

BACKGROUND

Data on long-term complications in adult patients with congenital heart disease (ACHD) and a prosthetic valve are scarce. Moreover, the influence of prosthetic valves on quality of life (QoL) and functional outcome in ACHD patients with prosthetic valves has not been studied.

OBJECTIVES

The primary objective of the PROSTAVA study is to investigate the relation between prosthetic valve characteristics (type, size and location) and functional outcome as well as QoL in ACHD patients. The secondary objectives are to investigate the prevalence and predictors of prosthesis-related complications including prosthesis-patient mismatch.

METHODS

The PROSTAVA study, a multicentre cross-sectional observational study, will include approximately 550 ACHD patients with prosthetic valves. Primary outcome measures are maximum oxygen uptake during cardiopulmonary exercise testing and QoL. Secondary outcomes are the prevalence and incidence of valve-related complications including prosthesis-patient mismatch. Other evaluations are medical history, physical examination, echocardiography, MRI, rhythm monitoring and laboratory evaluation (including NT-proBNP).

IMPLICATIONS

Identification of the relation between prosthetic valve characteristics in ACHD patients on one hand and functional outcome, QoL, the prevalence and predictors of prosthesis-related complications on the other hand may influence the choice of valve prosthesis, the indication for more extensive surgery and the indication for re-operation.

Diagnostic evaluation of left-sided prosthetic heart valve dysfunction

Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.

Factors affecting survival after mitral valve replacement in patients with prosthesis-patient mismatch

BACKGROUND

The purpose of this study was to determine the impact of prosthesis-patient mismatch on long-term survival after mitral valve replacement.

METHODS

From 1992 to 2008, 765 patients underwent bioprosthetic (325; 42%) or mechanical (440; 58%) mitral valve replacement, including 370 (48%) patients older than 65 years of age. Prosthesis-patient mismatch was defined as severe (prosthetic effective orifice area to body surface area ratio <0.9 cm(2)/m(2)), moderate (0.9 to 1.2 cm(2)/m(2)), or absent (>1.2 cm(2)/m(2)).

RESULTS

Multivariate analysis identified nine risk factors for late death including advanced age, earlier operative year, chronic renal insufficiency, peripheral vascular disease, congestive heart failure, nonrheumatic origin, concomitant coronary artery bypass grafting, lower body surface area, and more severe prosthesis-patient mismatch (lower effective orifice area to body surface area ratio; p < 0.05). For bioprosthetic recipients older than 65 years of age, survival at 5 and 10 years was 30% ± 7% and 0% ± 0% with severe mismatch compared with 43% ± 4% and 21% ± 5% for absent or moderate mismatch, respectively (p = 0.05). For mechanical recipients younger than 65 years of age, survival at 5 and 10 years was 77% ± 4% and 62% ± 6% with moderate or severe mismatch compared with 82% ± 3% and 66% ± 4%, respectively, without mismatch (p = 0.08).

CONCLUSIONS

Severe mismatch adversely affected long-term survival for older patients receiving bioprosthetic valves. With mechanical valves, there was a trend toward impaired survival when mismatch was moderate or severe in younger patients. Thus, selection of an appropriate mitral prosthesis warrants careful consideration of age and valve type.

Effect of prosthesis-patient mismatch on long-term survival with mitral valve replacement: assessment to 15 years

BACKGROUND

The effect of prosthesis-patient mismatch on long-term survival after mitral valve replacement (MVR) has received limited attention. This study was performed to determine the predictors of mortality after MVR and influence of prosthesis-patient mismatch on survival.

METHODS

Contemporary mechanical prostheses and bioprostheses were implanted in 2,440 patients with MVR between 1982 and 2002. The mean age was 63.9 +/- 12.1 years and the mean follow-up was 6.1 +/- 4.6 years, a total of 14,797.7 years of follow-up. Prosthesis-patient mismatch was classified by effective orifice area index categories: normal, greater than 1.2 cm(2)/m(2) (345, 14.2%); mild-to-moderate, equal to or less than 1.2 to greater than 0.9 cm(2)/m(2) (1,696, 69.5%); and severe, equal to or less than 0.9 cm(2)/m(2) (399, 16.4%).

RESULTS

The predictors of overall mortality were age, age categorization, New York Heart Association III-IV, concomitant coronary artery bypass, ventricular dysfunction, prosthesis type, body mass index, and pulmonary hypertension. All categories of effective orifice area indices (EOAIs) were not predictive of overall mortality, late mortality, or early mortality. The 15-year survival was not differentiated by EOAI categories; 32.0 +/- 4.4%, 32.9 +/- 2.1%, and 36.6 +/- 6.3%, respectively, for the three categories. Pulmonary hypertension influenced mortality by EOAI categories; normal versus mild-to-moderate (p = 0.0317) and normal versus severe (p = 0.0320). The EOAI was not an independent predictor of mortality in the consideration of patients with pulmonary hypertension but there is an interaction between pulmonary hypertension and mild-to-moderate (p = 0.023) and severe (p = 0.031) EOAI.

CONCLUSION

Prosthesis-patient mismatch is not a predictor of overall mortality to 15 years after MVR regardless of the category of effective orifice area index. The preoperative variable, pulmonary hypertension, influences overall mortality in the presence of mild-to-moderate and severe prosthesis-patient mismatch in the survival analysis.