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A Multi-Institutional Study on the Prevalence and Clinical Impact of Patient-Prosthesis Mismatch in Surgical Aortic
Lucy Nam1, Ruby Singh1, Sameer A Hirji2
1Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.
Background:
Prosthesis-patient mismatch (PPM) impacts surgical aortic valve replacement outcomes, with known associations with adverse clinical consequences. However, contemporary understanding of PPM's clinical implications, trends, and predictive factors remains limited.
Methods:
This multi-institutional study included all patients undergoing surgical aortic valve replacement between 2002 and 2023. PPM was calculated using effective orifice area indexed to body surface area (EOAi), categorized as moderate (EOAi ≤0.85 cm2/m2) or severe (EOAi ≤0.65 cm2/m2), with modified criteria for patients with body mass index ≥30 kg/m2 according to Valve Academic Research Consortium 3 guidelines. Clinical outcomes and predictors were assessed using Kaplan-Meier and multivariable analysis.
Results:
Among 10,607 surgical aortic valve replacement patients, 8102 (76%) had no PPM, 2333 (22%) had moderate PPM, and 172 (2%) had severe PPM. PPM prevalence declined over the last decade (31% to 18%, P < .05), coinciding with larger prosthetic valves (size 23 [SD, 2] mm to 24 [SD, 2] mm, P < .05) and increased annular enlargement (2.4% to 6.0%, P < .05). PPM was associated with higher 30-day mortality (odds ratio, 1.46; 95% CI 1.13-1.88; P < .05) and reduced long-term survival. Age- and sex-stratified analysis revealed a stronger association between advanced age and PPM risk in women compared with men (odds ratio, 2.31 vs 1.66 for age >74 vs <65 years; both P < .05).
Conclusions:
PPM prevalence has declined through technical improvements and evolving patient selection but remains a significant predictor of adverse outcomes. The pronounced risk in older female patients highlights the need for targeted surgical strategies, including careful prosthesis selection and consideration of annular enlargement in high-risk groups.
Insights
Prosthesis-patient mismatch (PPM) after aortic valve replacement is declining but still linked to worse outcomes. Older women face higher PPM risks, needing tailored surgical approaches.
Area of Science:
- Cardiology
- Cardiac Surgery
- Biomedical Engineering
Background:
- Prosthesis-patient mismatch (PPM) negatively impacts surgical aortic valve replacement (SAVR) outcomes.
- Limited contemporary understanding of PPM's clinical implications, trends, and predictors exists.
Purpose of the Study:
- To investigate current trends in PPM prevalence and its association with clinical outcomes after SAVR.
- To identify predictors of PPM, with a focus on age and sex differences.
Main Methods:
- Multi-institutional study of 10,607 patients undergoing SAVR (2002-2023).
- PPM assessed by effective orifice area indexed to body surface area (EOAi), with modified criteria for obesity (BMI ≥30 kg/m²).
- Outcomes analyzed using Kaplan-Meier and multivariable analyses, stratified by age and sex.
Main Results:
- PPM prevalence decreased from 31% to 18% over the last decade, associated with larger prostheses and increased annular enlargement.
- PPM linked to higher 30-day mortality (OR 1.46) and reduced long-term survival.
- Advanced age posed a greater PPM risk for women than men (OR 2.31 vs 1.66).
Conclusions:
- Despite declining prevalence due to technical advances, PPM remains a significant predictor of adverse SAVR outcomes.
- Older female patients exhibit a pronounced risk, necessitating targeted strategies like careful prosthesis selection and consideration of annular enlargement.
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