ECHO 2013 / Echocardiography for Assessment of Prosthetic Heart Valves
.pdf
Impact of Valve Prosthesis-Patient Mismatch on Short-Term Mortality after Aortic Valve Replacement
Claudia Blais, Jean Dumesnil,
Richard Baillot, Serge Simard,
Daniel Doyle, and Philippe Pibarot
Circulation 108; August 26, 2003; 983-988
©2011 MFMER | slide-31
1266 Consecutive Patients Undergoing Aortic Valve Replacement
Independent Predictors of 30 day Mortality
•LVEF < 40%
•Infective endocarditis
•Emergent/salvage operation
•Cardio-pulmonary bypass time > 120 min
•Prosthesis-patient mismatch
Blais C; Circ 108; 8/26/03; 983-988
©2011 MFMER | slide-33
Prosthesis-Patient Mismatch
•2,576 patients who survived > 30 days after AVR
•Indexed EOA estimated from reported in vivo data
Impact of Prosthesis-Patient Mismatch on Long-term Survival
•Severe PPM was associated with increased mortality in the entire cohort
•Severe PPM was associated with increased mortality for patients < 70 yr and for patients with BMI < 30 kg/m2
•No impact for older patients or obese patients
•Moderate PPM affected survival for patients with LVEF < 50%
Mohty D; JACC 53; 2009
Prosthesis-patient mismatch (PPM)
•Does not often result in aortic valve mean gradients as large as 40-50 mmHg
•Occurs in the setting of LV hypertrophy that developed with severe aortic stenosis
•The higher mean gradient with PPM does not allow hypertrophy to regress to the same extent that it regresses for patients without PPM
©2011 MFMER
Prosthesis-Patient Mismatch
Two Implications For Which There Should Be
No Debate
1.For patients with decreased LV function the predicted post-op mean gradient should weigh heavily in the choice of prosthetic aortic valve
2.PPM is associated with high mean gradients, and the Echo Lab is frequently faced with distinguishing this functional stenosis from pathologic stenosis
Aortic Prosthesis with Large Mean Gradient
•Thrombus
•Pannus
•Thrombus plus pannus
•Degenerative stenosis (tissue valve)
•Significant AR
•High output
•Prosthesis-patient mismatch
•Pressure recovery phenomenon
CW Jet Contour May Help Separate
Pathologic Obstruction
From Functional Obstruction
Think Pathologic With
•Rounded jet contour
•Jet acceleration time > 100 msec
JASE 22(9); September 2009
79 Year Old Woman
21 mm Tissue AVR
•LVIDd 49 mm; LVEF 68%
•SVI 48 cc/m2
•EOA 1.2 cm2
•EOAi 0.67 cm2/m2
•MG 22 mmHg
Pathologic obstruction or prosthesis-patient mismatch?