Patient –Prosthesis Mismatch

Vera H. Rigolin, MD, FASEVice-President, American Society of Echocardiography

Professor of MedicineNorthwestern University

Bluhm Cardiovascular InstituteMedical Director, Echocardiography Laboratory

Northwestern Memorial HospitalChicago, IL USA

No Disclosures

Circulation 1978; 58: 20-4

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

“Le maladie du Pibarot”

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

Methods to Calculate PPM

• EOAi calculated by echo using the continuity equation

– Normal: >0.85 cm2/m2– Moderate: 0.6-0.85 cm2/m2– Severe: <0.6 cm2/m2

• Manufactures’ charts• ASE Guidelines

– Peak velocity, mean gradient, AT, EOAi

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

History

• 75 yr old female with symptomatic aortic stenosis.

• Underwent AVR with a 21 mm Edwards Pericardial Magna Valve

• Ht: 5’6.5”• Wt: 188 lbs• BSA: 1.96 m2• BMI:29.9

Echo Post op

PV= 3.2 m/secMean Grad=23 mmHgDVI=0.33EOA=1.0 cm2EOAi=0.5 cm2AT=90 msecSV=75 ml

Manufacturer’s table

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

Effect of EOAi on Survival

Pibarot and Dumesnil. Heart 2006; 92: 1022-9

Survival According to LVEF

Jamieson et al. Ann Thorac Surg 2010; 89: 51-9

• 1982-2003• 3,343 patients ( 2493 bio – (CE Perimount 667) and 850 MP)• Projected EOA• F/u 6.2 ± 5 yrs

Jamieson et al. Ann Thorac Surg 2010; 89: 51-9

Jamieson et al. Ann Thorac Surg 2010; 89: 51-9

• Moderate PPM 52%

• Severe PPM 27%

Florath et al. Am Heart J 2008; 155: 1135-42

Florath et al. Am Heart J 2008; 155: 1135-42

Mohty-Echahidi et al. Circ 2006; 113: 420-6

• 1985-2000• 388 patients who underwent St. Jude AVR• Echo within 1 yr after AVR• Severe PPM EOAI < 0.6 cm/m2, Mod 0.6-0.85 cm/m2,

Normal > 0.85 cm/m2)• Severe 66 ( 17%), Moderate 168 ( 43%), normal ( 40%)

Mohty-Echahidi et al. Circ 2006; 113: 420-6

Mohty-Echahidi et al. Circ 2006; 113: 420-6

Mohty-Echahidi et al. Circ 2006; 113: 420-6

• 571 pts who had a bioprosthetic AVR• 1/2005- 12/2008• 146( 26%) were included in this study• Inclusion:• Normal LVEF• Baseline and follow up echo at least 6 months after the date of

surgery• PPM assessed with 1) ASE methods, 2) manufacturer’s table, and

3) measured EOAiChacko et al. Circ Img 2013; 6: 776-83

Chacko et al. Circ Img 2013; 6: 776-83

Chacko et al. Circ Img 2013; 6: 776-83

Treatment

• Avoid severe PPM–Enlarge aortic root–Use stentless valve or other low

profile prosthesis• May tolerate mild to mod PPM in

an older/sedentary patient• Females and large BSA at most risk

Summary

• Various methods to calculate PPM • Echo-derived EOAi is dependent on

accurate measurements• Severe PPM may impact survival• Pts with low EF most vulnerable • Avoidance of PPM is the best

treatment

Thank You