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Patient-prosthesis mismatch (PPM) is a commonly neglected issue in aortic valve replacement patients, associated to several complications. These biological surgical valves eventually fail and patients may undergo valve-in-valve. We evaluate whether severe predicted PPM is a predictor of mortality in the valve-in-valve population.
Predicted PPM is derived from reference effective orifice area (EOA) values for each surgical valve size model and size divided by body surface area (BSA) (i.e. indexed EOA). Moderate PPM was defined as indexed EOA (iEOA) ≤ 0.85 cm2/m2 for body mass index (BMI) < 30 kg/m2 or iEOA ≤ 0.7 cm2/m2 for BMI ≥ 30 kg/m2. Severe PPM was defined as iEOA ≤ 0.65 cm2/m2 for body mass index (BMI) < 30 kg/m2 or iEOA ≤ 0.55 cm2/m2 for BMI ≥ 30 kg/m2. Reference EOA values were available for Medtronic Mosaic, Medtronic Hancock II, Medtronic Mosaic, Carpentier-Edwards, Carpentier-Edwards Perimount, Carpentier-Edwards Perimount Magna, Sorin Mitroflow and St. Jude Toronto SPV. Multivariate analysis was performed to identify independent predictors of one-year mortality, including as possible variables severe predicted PPM, any predicted PPM, presence of small surgical valve (label size ≤ 21mm) and mechanism of failure.
1,023 patients with the valves above were selected from the Valve-in-Valve International Data (VIVID) Registry. Mean age was 78.4 ± 8.6 years and mean STS was 9.7 ± 8.6%. 48 patients had severe predicted PPM and 509 had moderate predicted PPM.
One year survival was significantly different between severe predicted PPM patients versus others (71.8% vs. 85.9%, log-rank p-value 0.02). In multivariate regression, severe predicted PPM was identified as the strongest independent predictor for one-year mortality (HR 2.12; CI 1.08–4.2; p-value = 0.03), followed by STS Score (HR 1.04, CI 1.03–1.06; p-value < 0.001). Presence of small surgical valve and mechanism of failure were not identified as end-point predictors.
Predicted severe PPM is an easily assessable measure and is an independent predictor of long-term mortality in aortic valve-in-valve patients. This parameter may provide operators a strong tool to enhance patient selection for the procedure.