Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE...

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Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography Professor of Medicine Northwestern University Bluhm Cardiovascular Institute Medical Director, Echocardiography Laboratory Northwestern Memorial Hospital Chicago, IL USA

Transcript of Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE...

Page 1: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 2: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

No Disclosures

Page 3: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

Circulation 1978; 58: 20-4

Page 4: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

“Le maladie du Pibarot”

Page 5: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 6: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 7: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 8: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 9: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 10: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 11: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 12: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 13: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 14: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 15: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

Echo Post op

Page 16: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern
Page 17: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 18: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

Manufacturer’s table

Page 19: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Effect of EOAi on Survival

Page 20: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Survival According to LVEF

Page 21: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 22: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

• 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

Page 23: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 24: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern
Page 25: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

• Moderate PPM 52%

• Severe PPM 27%

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

Page 26: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 27: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 28: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

• 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

Page 29: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 30: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 31: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

• 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

Page 32: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 33: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 34: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 35: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

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

Page 36: Patient –Prosthesis Mismatch · Patient –Prosthesis Mismatch Vera H. Rigolin, MD, FASE Vice-President, American Society of Echocardiography. Professor of Medicine. Northwestern

Thank You

Presenter
Presentation Notes
  Thank you for your time and attention and I’d be happy to take any questions at this time.

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