Patient/prosthesis mismatch: how to evaluate and when to act?
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1 Patient/prosthesis mismatch: how to evaluate and when to act? Svend Aakhus, MD, PhD Oslo University Hospital, Norway Disclosures: No conflict of interest
2 Types of aortic valve prostheses (AVR) Mechanical single disk Mechanical bi-leaflet AVR Stented bio-prosthesis Stentless bio-prosthesis
3 Definition of patient/prosthesis mismatch, PPM Valve orifice area inadequate in a patient despite normal function of the prosthesis Pibarot P and Dumesnil JG. JACC 2000;36:1131
4 mean AVR gradient (mmhg) Classification of PPM Severe PPM: EOAi < 0.65 cm 2 /m 2 rest Moderate PPM: 0.65 EOAi 0.85 cm 2 /m 2 No PPM: EOAi > 0.85 cm 2 /m 2 peak exercise Pibarot P and Dumesnil JG. JACC 2000;36:1131
5 Prevalence of AVR PPM Severe (EOAi<0.65 cm 2 /m 2 ): 2% Moderate (EOAi cm 2 /m 2 ): 31% Normal (EOAi>0.85 cm 2 /m 2 ): 67% Mohty D et al. JACC 2009;53:39
6 Patient example F 73 yrs St. Jude 19, NYHA II Vmax 3.6 m/s MG 24 mmhg EOA 1.1 cm 2 AVR dysfunction? JG yrs later: NYHA II Vmax 3.8 m/s MG 31 mmhg EOA 0.9 cm 2
7 Causes of increased AVR gradient Patient-prosthesis mismatch (PPM) Gorlin equation Pressure recovery ΔP = [ CO ] k. A 2 Increased flow Obstruction LVOT AVR malfunction AVR gradient relates to: Transvalvular flow Effective orifice area
8 Determinants of AVR gradient AVR bioprosthesis In vitro study Dumesnil JG and Yoganathan AP. Eur J Cardiothorac Surg 1992;6:34
9 Evaluation of AVR AVR maximal blood flow velocity AVR mean gradient AVR Doppler acceleration time/ velocity profile Doppler velocity index (DVI) Effective orifice area (EOA) Fluoroscopy
10 AVR, Doppler flow Maximal blood flow velocity, Vmax AV Mean gradient, MG ΔP =4 v 2 Acceleration time, AT Doppler velocity index, DVI: CW AVR VTI AV MG Vmax AV PW LVOT DVI Vmax = Vmax LVOT Vmax AV VTI LVOT Vmax LVOT AT DVI VTI = VTI LVOT VTI AV
11 AVR effective orifice area, EOA Doppler LVOT LVOT CSA Doppler AVR PW Doppler LVOT VTI LVOT Continuity equation, EOA: EOA = CSA LVOT x VTI LVOT VTI AV CSA LVOT = π(d/2) 2 CW Doppler AVR VTI AV EOAi = EOA/BSA (cm 2 /m 2 )
12 LVOT diameter in AVR LVOTd Ao AML HEA270759
13 AVR, fluoroscopy Knowledge of: Prosthesis characteristics Leaflet opening angle HSG261166
14 AVR prosthesis function Echo parameters: Normal Significant stenosis Peak velocity, m/s <3 >4 Mean gradient, mmhg <20 >35 AT, ms <80 >100 CW jet contour Triangular Rounded DVI 0.30 <0.25 EOA, cm 2 >1.2 <0.8 Adapted from: Zoghbi WA et al JASE 2009;22:975
15 Causes of increased AVR gradient JG F 73 yrs St. Jude 19, NYHA II Vmax 3.6 m/s MG 24 mmhg AT 72 ms DVI VTI 0.34 EOAi 0.7 cm 2 /m 2 - PPM 5 yrs later: NYHA II Vmax 3.8 m/s MG 31 mmhg AT 65 ms DVI VTI 0.32 EOAi 0.6 cm 2 /m 2 Severe PPM?
16 Expect PPM in patients with: Larger BSA Smaller LVOT diameters Native aortic valve stenosis Older age (>70 years) Calcified aortic annulus
17 Consequences of PPM Increased AVR gradient Increased LV work Sustained LV hypertrophy Clinical symptoms Increased mortality and morbidity
18 PPM: 30-days relative mortality risk Blais C et al. Circulation 2003;108:983
19 PPM and long-term prognosis severe PPM moderate PPM Mohty D et al. JACC 2009;53:39
20 Other causes of increased AVR gradient - pressure recovery phenomenon Bileaflet prostheses, central high velocity jet EOA corrected for pressure recovery Energy loss coefficient: E L Co = EOA x Ao A Ao A - EOA Bach DS JACC CV img 2010;3:296 Small asc. aorta diameter ( 3.0 cm)
21 Other causes of increased AVR gradient - increased flow M 51 yrs CM23, NYHA III Vmax 3.7 m/s MG 32 mmhg DVI VTI 0.36 EOAi 0.6 cm 2 /m 2 AT 97 ms Severe paravalvular AR HEA270759
22 Other causes of increased AVR gradient - obstruction, AVR malfunction F 38 yrs Mosaic 23, NYHA II Vmax 3.7 m/s MG 33 mmhg DVI VTI 0.27 EOAi 0.6 cm 2 /m 2 AT 120 ms Significant bio-prosthesis stenosis AEB160471
23 Characteristics of PPM induced high AVR gradient Smaller AVR and/or larger BSA High gradient early after AVR Sustained gradients over years Normal DVI and AT EOA within reference range Normal fluoroscopy
24 Prevention of PPM problems Pre-operative Identify LVOT/BSA discrepancy Identify reduced LV function Select AVR prosthesis: Ideally EOA > 0.9 cm 2 x BSA Per-operative Maximize AVR EOA If PPM is likely: consider stentless bioprosthesis, aortic root enlargement, xeno- or homografts Post-operative Early baseline echocardiography
25 When to re-operate in AVR PPM Severe PPM (EOAi < 0.65 cm 2 /m 2 ) Significant daily life symptoms Dyspnea/fatigue Anginous chest pain Syncope Technical availability Risk vs. benefit consideration
26 In summary, PPM Is prevalent after AVR Impairs symptomatic improvement and survival after AVR May be prevented by pre- and peroperative considerations Re-op. indicated in selected patients
27
28 Reasons for over-estimating PPM High flow situation Febrilia, anemia, hyperthyroidism, etc Pressure recovery Small ascending aortic diameter (<3.0 cm) Central jet in bileaflet AVR Technical Contamination of AVR signal by MR signal Erroneous overtracing of Doppler signal Angle correction of Doppler
29 Reasons for underestimating PPM Low-flow situation Technical: Angle deviation > 20 degrees
30 Systematic evaluation of elevated AVR gradient Zoghbi WA et al JASE 2009;22:975
31 Bach D JACC img 2010
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