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Impact of prosthesis-patient mismatch on survival after mitral valve replacement
Julien Magne1, Patrick Mathieu, Jean G Dumesnil
1Laval Hospital Research Center/Québec Heart Institute, Faculty of Medicine, Laval University, Québec, Canada.
Background:
We recently reported that valve prosthesis-patient mismatch (PPM) is associated with persisting pulmonary hypertension after mitral valve replacement. Thus, the objective of this study was to evaluate the impact of PPM on mortality in patients undergoing mitral valve replacement.
Methods And Results:
The indexed valve effective orifice area was estimated for each type and size of prosthesis being implanted in 929 consecutive patients and used to define PPM as not clinically significant if > 1.2 cm2/m2, as moderate if > 0.9 and < or = 1.2 cm2/m2, and as severe if < or = 0.9 cm2/m2. Moderate PPM was present in 69% of patients; severe PPM was seen in 9%. For patients with severe PPM, 6-year survival (74+/-5%) and 12-year survival (63+/-7%) were significantly less than for patients with moderate PPM (84+/-1% and 76+/-2%; P=0.027) or nonsignificant PPM (90+/-2% and 82+/-4%; P=0.002). On multivariate analysis, severe PPM was associated with higher mortality (hazard ratio, 3.2; 95% confidence interval, 1.5 to 6.8; P=0.003).
Conclusions:
Severe PPM is an independent predictor of mortality after mitral valve replacement. As opposed to other independent risk factors, PPM may be avoided or its severity may be reduced with the use of a prospective strategy at the time of operation. For patients identified as being at risk for severe PPM, every effort should be made to implant a prosthesis with a larger effective orifice area.
Insights
Severe prosthesis-patient mismatch (PPM) after mitral valve replacement significantly increases mortality risk. Careful prosthesis selection can mitigate this risk, improving long-term survival for patients undergoing this procedure.
Area of Science:
- Cardiovascular Surgery
- Medical Device Performance
- Prosthetic Heart Valves
Background:
- Prosthesis-patient mismatch (PPM) is linked to persistent pulmonary hypertension post-mitral valve replacement.
- Understanding PPM's impact on mortality is crucial for surgical outcomes.
Purpose of the Study:
- To investigate the effect of PPM on mortality in patients who have undergone mitral valve replacement.
Main Methods:
- Indexed valve effective orifice area was calculated for 929 patients.
- PPM severity was categorized: not clinically significant (>1.2 cm2/m2), moderate (>0.9 to ≤1.2 cm2/m2), and severe (≤0.9 cm2/m2).
Main Results:
- Severe PPM occurred in 9% of patients; moderate PPM in 69%.
- Six- and 12-year survival rates were significantly lower for severe PPM patients (74% and 63%) compared to moderate (84% and 76%) or non-significant PPM (90% and 82%).
- Multivariate analysis identified severe PPM as a significant predictor of higher mortality (HR, 3.2; P=0.003).
Conclusions:
- Severe PPM is an independent predictor of mortality following mitral valve replacement.
- Proactive strategies to avoid or reduce PPM severity during surgery are recommended.
- Implanting larger effective orifice area prostheses is advised for at-risk patients.
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