How to Avoid Prosthesis-Patient Mismatch
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1 How to Avoid Prosthesis-Patient Mismatch Philippe Pibarot, DVM, PhD, FACC, FAHA, FASE, FESC Canada Research Chair in Valvular Heart Diseases INSTITUT UNIVERSITAIRE DE CARDIOLOGIE ET DE PNEUMOLOGIE DE QUÉBEC Université LAVAL
2 BSA EOA PATIENT S CARDIAC OUTPUT REQUIREMENTS PROSTHETIC VALVE EOA PPM occurs when the EOA of the prosthesis is too small in relation to patient s body size / cardiac output requirements
3 Severity and Prevalence of PPM in the Aortic Position SEVERE MODERATE MILD/NONE (non significant) Indexed EOA (cm 2 /m 2 ) 0.65 ( ) 0.85 ( ) Prevalence 5-25% 20-70%
4 Impact of PPM on Clinical Outcomes Less regression of LVH Less recovery of coronary flow reserve Less regression of mitral regurgitation Less improvement in functional class / exercise capacity Increased incidence of late cardiac events Increased incidence of bioprosthesis SVD Negative impact on short- and long-term survival particularly if LV dysfunction Pibarot & Dumesnil, 92:1022-9, 2006 Pibarot & Dumesnil, JACC 2000; 36:
5 Head et al Eur Heart J. 33: ;2012
6 Impact of PPM on All-Cause Mortality Head et al Eur Heart J. 33: ;2012
7 Impact of PPM on Cardiac Mortality Head et al Eur Heart J. 33: ;2012
8 Head et al Eur Heart J. 33: ;2012
9 Prevention of PPM
10 Recommendations for the Prevention of PPM Avoid severe PPM (EOAI<0.65) in every patient undergoing AVR Avoid moderate PPM (EOAI<0.85) in: Patients with LV dysfunction a/o severe LVH Patients with concomitant MR Young (< yr) patients Athlete patients
11 Calculate the Projected Indexed EOA to Predict Risk of PPM Hypothetical Prosthesis Model Pibarot & Dumesnil, 92:1022-9, 2006
12 Options to Prevent PPM 1- Use better performing prosthesis Newer generation supra-annular bioprosthesis Newer generation mechanical prosthesis Stentless bioprosthesis Sutureless bioprosthesis 2- Aortic root enlargement 3- Transcatheter aortic valve implantation
13 Option #1: Use of prosthesis with better hemodynamic performance and thus better EOAbility
14 Prospective Randomized Study: Mosaic vs. CEP standard 100 patients: intra-operative randomization to Mosaic or CEP standard 1 Indexed EOA (cm 2 /m 2 ) 0,9 0,8 * * 0,7 MOSAIC CEP 0,6 0, Walther et al. Circulation; 110: II-74-78, 2004
15 PPM in New Generations of Bioprosthetic Valves Results of the St Jude Medical Trifecta Multicenter Clinical trial Mild to Moderate PPM: 22% Severe PPM: 2% Bavaria et al. JTCS 147:590-7; 2014
16 RCT of Minimally Invasive Rapid Deployment Versus Conventional Full Sternotomy AVR XCL Bypass Time: 41 min 54 min p<0.001 Severe PPM at 3 months: 0% 15% p=0.04 Borger et al. Ann Thorac Surg 99:17 25, 2015
17 Option #2: Aortic root enlargement
18 Prospective Strategy to Avoid PPM 657 consecutive patients age: years, 61 % women, BSA: m 2 Projected indexed EOA 0.85 cm 2 /m 2 Enlargement of aortic root + AVR: 114 pts (17%) > 0.85 cm 2 /m 2 Standard AVR: 543 pts (83%) Prevalence of mismatch: 2.6 % 2.4 % Operative mortality: 0.9 % 4.1 % Castro et al., Ann Thorac Surg, 74, 2002.
19 Option #3: Transcatheter Aortic Valve Replacement
20 Severe Prosthesis-Patient Mismatch in Transcatheter vs. Surgical Valves VS. VS. Clavel et al., JACC, 53; , 2009
21 Prosthesis-Patient Mismatch in PARTNER-IA: Whole Cohorts TAVR vs. SAVR Subsets with Small Aortic Annulus (<20 mm) Pibarot et al. J Am Coll Cardiol 2014;64:
22 TAVR has less PPM but more PVL than SAVR Pibarot et al. JACC 64: , 2014
23 Survival According to Annulus Size and Treatment: TAVR vs. SAVR Small Annulus Tertile All-cause mortality (PARTNER-I Cohort A - RCT) Medium Annulus Tertile Large Annulus Tertile Rodés-Cabau et al. Circ Intervention 2014
24 All-Cause Mortality ACC 2015 Δ = 6.5 Δ = % 28.6% 22.2% 14.1% Log-rank P=0.04 No. at Risk Months Post-Procedure Transcatheter Surgical
25 Paravalvular Regurgitation (Paired) ACC
26 Echocardiographic Findings TAVR had significantly better valve performance over SAVR at all follow-up visits (P<0.001) ACC
27 Prevention of PPM: Conclusions Severe PPM has a significant impact on mortality & morbidity, whereas moderate PPM may have a significant effect in vulnerable subsets of patients There are now several options to prevent PPM: newer generations of prostheses including sutureless valves, aortic root enlargement, TAVR Preventive strategy should be individualized according to the anticipated severity of PPM and the patient s baseline risk profile
28 In the Field of Heart Valves, Size Matters!
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