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A Simplified Stepwise Approach to Echo Guidance during Percutaneous Mitral Valve Repair
Published on: October 16, 2021
Effect of prosthesis patient mismatch in mitral position on pulmonary hypertension
Ganesh Kumar K Ammannaya1, Prashant Mishra1, Jayant V Khandekar1
1Department of Cardiovascular & Thoracic Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India.
Objectives:
Pulmonary arterial hypertension (PAH) is associated with poor outcome after mitral valve replacement (MVR). We proposed to evaluate the effect of valve prosthesis patient mismatch (PPM) on pulmonary arterial (PA) pressure following MVR.
Methods:
Five hundred patients who have undergone MVR were studied retrospectively. Postoperative PA systolic pressure (PASP) measured 6 months postoperatively by Doppler echocardiography was compared with preoperative values. PASP ≥ 40 mmHg was defined as PAH. Mitral valve effective orifice area was calculated by the continuity equation and indexed for body surface area. PPM was defined as indexed effective orifice area ≤ 1.2 cm2/m2. A multivariate model was constructed to ascertain the independent determinants of systolic PA pressure. Also, a propensity score model was constructed to overcome the baseline differences between the PPM and no PPM groups.
Results:
The incidence of PPM in this study was 37.2%. The average postoperative PASPs were 30.49 and 42.35 mmHg in the no PPM and PPM groups, respectively; (P < 0.001). Regression of PAH in the PPM and no PPM groups was 76.26% and 20.64%, respectively; (P < 0.001). The indexed effective orifice area correlated well with postoperative PASP (r = 0.71). The overall survival and freedom from cardiac death at 10 years were 79.8% and 85.3%; and at 20 years were 66.5% and 74.3%, respectively. Both, overall survival and the freedom from cardiac death were higher in the no PPM group than in the PPM group; (P < 0.001). Propensity score matching analysis yielded 112 pairs of the PPM and no PPM cohorts, which revealed higher overall survival and freedom from cardiac death in the no PPM group; (P = 0.028 and 0.012, respectively).
Conclusions:
Mitral PPM is an independent predictor of persistent PAH after MVR along with associated morbidity and reduced survival.
Insights
Prosthesis-patient mismatch (PPM) after mitral valve replacement (MVR) is linked to persistent pulmonary arterial hypertension (PAH) and reduced survival. Avoiding PPM improves patient outcomes and survival rates post-MVR.
Area of Science:
- Cardiology
- Cardiac Surgery
- Pulmonary Hypertension
Background:
- Pulmonary arterial hypertension (PAH) significantly worsens outcomes following mitral valve replacement (MVR).
- Prosthesis-patient mismatch (PPM), a condition where the prosthetic valve is too small for the patient, is a potential contributor to poor outcomes after MVR.
Purpose of the Study:
- To evaluate the impact of prosthesis-patient mismatch (PPM) on pulmonary arterial (PA) pressure after mitral valve replacement (MVR).
- To determine if PPM is an independent predictor of persistent PAH and its effect on survival after MVR.
Main Methods:
- Retrospective analysis of 500 patients undergoing MVR.
- Comparison of pre- and post-operative pulmonary arterial systolic pressure (PASP) using Doppler echocardiography at 6 months.
- Definition of PAH as PASP ≥ 40 mmHg; PPM defined as indexed effective orifice area ≤ 1.2 cm²/m².
- Multivariate and propensity score matching analyses to identify independent determinants of PA pressure and overcome baseline differences.
Main Results:
- The incidence of PPM was 37.2%.
- Postoperative PASP was significantly higher in the PPM group (42.35 mmHg) compared to the no PPM group (30.49 mmHg).
- Regression of PAH was significantly lower in the PPM group (20.64%) versus the no PPM group (76.26%).
- PPM was associated with reduced overall survival and freedom from cardiac death at 10 and 20 years.
- Propensity score matching confirmed higher survival and freedom from cardiac death in the no PPM group.
Conclusions:
- Mitral prosthesis-patient mismatch (PPM) is an independent predictor of persistent pulmonary arterial hypertension (PAH) after mitral valve replacement (MVR).
- PPM is associated with increased morbidity and reduced long-term survival following MVR.
- Optimizing prosthesis selection to avoid PPM is crucial for improving patient outcomes after MVR.
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