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Ann Thorac Surg 2005;79:505-510
© 2005 The Society of Thoracic Surgeons
a Department of Cardiac Surgery, Poliambulanza Hospital, Brescia, Italy
Accepted for publication April 12, 2004.
* Address reprint requests to Dr Tasca, UF di Cardiochirurgia, Poliambulanza Hospital, Via L. Bissolati 57, 25125 Brescia, Italy
cch-segreteria.poli{at}poliambulanza.it
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentReferences |
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METHODS: The aim of the study was to determine the impact of prosthesis-patient mismatch on the postoperative regression of left ventricular mass.
Left ventricular mass was measured by Doppler echocardiography in 109 patients undergoing aortic valve replacement with a single type of bioprosthesis (Carpentier-Edwards Perimount) for pure aortic stenosis. Prosthesis-patient mismatch was defined as a projected indexed effective orifice area less than 0.90 cm2/m2. On this basis, 58/109 (53.2%) patients had prosthesis-patient mismatch.
RESULTS: There was a good correlation (r = 0.61, p < 0.001) between the postoperative mean transprosthetic gradient and the projected indexed effective orifice area. The absolute and relative left ventricular mass regression was significantly (p = 0.002 and p = 0.01, respectively) lower in patients with prosthesis-patient mismatch (–48 ± 47 g, –17% ± 16%) compared to those with no prosthesis-patient mismatch (–77 ± 49 g, –24% ± 14%). In multivariate analysis, a larger projected indexed effective orifice area, female gender and a higher preoperative left ventricular mass are independent predictors of greater left ventricular mass regression.
CONCLUSIONS: This study shows that in patients with pure aortic stenosis prosthesis-patient mismatch is associated with lesser regression of left ventricular hypertrophy after aortic valve replacement. These findings may have important clinical implications given that prosthesis-patient mismatch is frequent in these patients.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Valve prosthesis-patient mismatch (PPM) is present when the effective orifice area (EOA) of the inserted prosthetic valve is too small relative to body surface area (BSA). PPM is defined as a valve effective orifice area indexed for body surface area (IEOA) equal to or greater than 0.8 to 0.9 cm2/m2 [6–9]. This is a frequent problem in patients undergoing AVR (20% to 70% prevalence), and its main hemodynamic consequence is to generate high transvalvular gradients through normally functioning prosthetic valves [7–10]. Residual transprothetic pressure gradients are important to consider because an increased gradient will evidently result in an increased LV workload, thus potentially jeopardizing the regression of LV mass after AVR. There has been very few studies on the impact of PPM on LV mass regression and there persists some controversy regarding this issue [11, 12].
The objective of this study was to examine if there is a relation between PPM and the extent of LV mass regression after AVR.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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The patients with more than mild aortic regurgitation, previous myocardial infarction, previous cardiac surgery, and concomitant surgical procedure other than coronary artery bypass grafting (CABG) were excluded.
After a clinical follow-up examination at 3 months, the patients were interviewed by telephone annually in order to assess their clinical status and collect survival data. The follow-up was 100% complete. The survivors were invited to undergo an echocardiographic control examination at our hospital between 12 and 24 months postoperatively.
Mismatch Definition
Previous studies have shown that PPM as well as its consequences on morbidity and mortality can be predicted at the time of operation by calculating the projected IEOA [9, 10, 13–15]. In the present study, the projected indexed IEOA was derived from the published normal in vitro EOA values for the type (CEP) and size of implanted prosthesis divided by the patient's BSA [15]. The in vitro EOA values were: 1.3 cm2 for the 19-mm valve, 1.5 cm2 for the 21-mm valve, 1.8 cm2 for the 23-mm valve, and 2.0 cm2 for the 25-mm valve. For the purpose of this study, PPM was defined as a projected IEOA of less than 0.90 cm2/m2 as suggested by Pibarot and Dumesnil [7, 9].
Doppler Echocardiographic Measurements
Patients were evaluated by Doppler echocardiography 0 to 7 days before operation and between 1 and 2 years after operation. The preoperative and postoperative echocardiographic studies were performed by four experienced echocardiographers using an Acuson 128 Computed Sonograph (Acuson, Mountain View, CA) equipped with 2.5- to 3.5-MHz transducers. The dimensions of the LV were assessed using two-dimensional guided M-mode tracings, with the measurements being made according to the recommendations of the American Society of Echocardiography (ASE) [16]. If the M-mode recordings were technically inadequate, two-dimensional measurements were used. LVM was calculated with the corrected ASE formula [17]:
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Statistical Analysis
The data were statistically analyzed using SPSS 9.0 software (SPSS Inc. Chicago, IL). The continuous variables were expressed as mean values ± standard deviation (SD) and compared using a two-tailed t test (paired or unpaired as appropriate). The normality of the distributions in the two groups was tested by means of the Shapiro-Wilk test and, when abnormal, the data were log transformed. The discrete variables were compared using the 
2 test. The relationship between the postoperative mean transprosthetic gradient and the projected IEOA was evaluated by means of simple linear regression analysis, after logarithmic transformation, in order to calculate r (Pearson's correlation coefficient). Multiple linear regression analysis was used to identify the independent predictors of LVM regression; p values of less than 0.05 were considered significant.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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21 mm) prosthesis had no PPM and, inversely, several patients with a larger prosthesis had PPM.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentReferences |
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A large amount of literature is available on the effect of AVR on LV hypertrophy regression. However, there are very few studies that directly address this issue in relation to PPM. In a study including 1103 patients with a porcine bioprosthetic valve, Del Rizzo and coworkers [11] found a strong and independent relationship between the indexed EOA and the extent of LV mass regression following AVR. There was a mean decrease in LV mass of 23% in patients with an indexed EOA of more than 0.8 cm2/m2 compared with only 4.5% in those with an indexed EOA of equal to or less than 0.8 cm2/m2 (p = 0.0001). In contrast to these results, Hanayama and associates [12] found no significant relationship between PPM and regression of LV hypertrophy. However, the majority of patients included in this retrospective study did not undergo a complete echocardiographic follow-up of LV mass (preoperative base line and/or postoperative measurements not available). Furthermore, 50% of the patients with severe PPM included in this study still had significant LV hypertrophy more than 5 years after AVR.
The major finding of our study is that PPM is associated with lesser regression of LV mass after AVR. Moreover, this association remained significant after adjustment for other relevant factors including gender and preoperative LV mass. This finding is consistent with the pressure gradient–indexed EOA relation, whereby the pressure gradient and thus the LV workload increase markedly when the IEOA becomes lower than 0.8 to 0.9 cm2/m2 [7, 8, 13, 32]. Previous studies have reported that PPM is associated with inferior hemodynamics, more cardiac events, and higher mortality rates after AVR [10, 14, 15, 33, 34]. The results of the present study suggest that the persistence of LV hypertrophy associated with PPM may be one of the factors contributing to the PPM-related adverse outcomes.
In our previous study of the CEP valve [23], we did not find any significant difference between 19-, 21-, and 23-mm CEP valve sizes in regards to LV mass regression. The results of the present study do not necessarily contradict our previous findings given that prosthesis size is not a good predictor of postoperative transprosthetic gradients and thus of PPM [13]. Accordingly, other studies have reported that IEOA (ie, the degree of PPM) but not prosthesis size are independent predictors of postoperative mortality [14, 15].
In the present study, we elected to use the projected IEOA rather than the postoperative IEAO to predict PPM for the several reasons. The IEOA measured by Doppler echocardiography after operation may be influenced by several factors (including subvalvular geometry, the orientation of the prosthesis, the nonuniformity of the subvalvular velocity profile, and measurement errors) [35]. In contrast, the projected IEOA is not affected by these factors and is not operator dependent. And more importantly, it can be calculated at the time of operation to predict PPM and can thus be used to prevent PPM as shown in previous studies [13, 36]. In this context, Pibarot coworkers [32] have demonstrated that the projected IEOA correlates well with postoperative resting and exercise transprosthetic gradients and that it can thus be used to identify the patients who have a high gradient on the basis of PPM. The good correlation found between the postoperative resting gradient and the projected IEOA, in the present study, further corroborate the results of Pibarot and colleagues [9]. It should be considered that the vast majority of the studies that have analyzed the impact of PPM on postoperative outcomes have used the projected IEOA to define PPM.
Clinical Implications
The clinical implication of this study may be important given that PPM is a frequent occurrence after AVR and that, as opposed to other risk factors, it can be prevented by implementing a preventive strategy at the time of operation [9, 13, 36]. Hence, if the projected IEOA of the prosthesis initially considered for implantation is less than 0.9 cm2/m2, the surgeon could either perform a supraannular implantation or an aortic root enlargement in order to implant a larger prosthesis of the same type or, alternatively, he could also attempt to implant another type of prosthesis with a larger EOA (eg, stentless bioprostheses or bileaflet mechanical valve of new generation).
Study Limitations
In the present study, we used in vitro EOAs to calculate the projected IEOA. Indeed, there has been relatively few data published in the literature regarding the in vivo EOAs of the CEP valve at 1 to 2 years after operation and these data are based on a small number of patients [37]. Nonetheless, previous studies reported that, for stented bioprostheses as well as for mechanical valves, there is a strong correlation between in vitro and in vivo EOAs, although in vitro EOAs tend to overestimate in vivo EOAs by 10 to 15% [7, 38].
Preoperative LV mass had a significant influence on the extent of LV mass regression after operation. The fact that patients with PPM had a lower preoperative LV mass may thus have contributed to the lower LV mass regression observed in these patients after AVR. Nonethless, it should be emphasized that the projected IEAO remained an independent predictor of LV mass regression even after adjusting for preoperative LV mass in mutlivariate analysis and the percentage of patients meeting the criteria for LV hypertrophy was higher in the mismatch group.
Regression of LV hypertrophy occurs in large part during the first 2 years after operation but it continues at a slower rate for several years thereafter [39, 40]. Longer follow-up of the patients included in this study is therefore necessary to determine if the difference between groups will increase over time.
Conclusion
This study shows that in patients with pure AS, PPM may hamper the regression of LV mass after AVR. These findings may have important clinical implications given that PPM is frequent in these patients and, as opposed to other risk factors, it can be avoided with the use of a preventive strategy at the time of operation.
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= mismatch; 
= no mismatch. (CEP = Carpentier-Edwards Perimount.)
= observed; 
= linear. (IEOA = indexed effective orifice area.)