Imaging for Predicting and Assessing Prosthesis-Patient Mismatch After Aortic Valve Replacement

Area of Science:

• Cardiology
• Cardiac Surgery
• Medical Imaging

Background:

• Prosthesis-patient mismatch (PPM) occurs when prosthetic valve size is inadequate for patient body size, leading to high postoperative pressure gradients.
• Severe PPM affects 2-20% of surgical aortic valve replacement (AVR) patients, increasing mortality and heart failure rehospitalization risk.
• Accurate assessment of PPM is crucial for optimizing patient outcomes after AVR.

Purpose of the Study:

• To provide an overview of multimodality imaging's role in the assessment, prediction, prevention, and management of PPM post-AVR.
• To highlight strategies for preventing PPM during surgical AVR.
• To discuss the differential diagnosis between PPM and prosthetic valve stenosis using imaging.

Main Methods:

• Risk assessment involves calculating predicted indexed effective orifice area (EOA) based on prosthesis and patient body surface area.
• Prevention strategies include implanting newer generation valves, aortic root/annulus enlargement, or considering transcatheter aortic valve replacement (TAVR).
• Multimodality imaging, including transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multidetector computed tomography (MDCT), is used for PPM assessment.

Main Results:

• PPM is characterized by high transprosthetic velocity/gradients, normal EOA, small indexed EOA, and normal leaflet function.
• TTE is primary for PPM identification, while TEE and MDCT are valuable for assessing leaflet morphology and mobility, differentiating PPM from pathologic valve obstruction.
• Severe symptomatic PPM may be managed with redo surgery or transcatheter valve-in-valve procedures.

Conclusions:

• Multimodality imaging plays a vital role in the comprehensive management of PPM following AVR.
• Early identification and appropriate management of PPM are essential for improving long-term patient prognosis.
• Tailored strategies, including valve selection and procedural techniques, can mitigate the risk and impact of PPM.