Valvular heart disease
Interaction and Prognostic Effects of Left Ventricular Diastolic Dysfunction and Patient-Prosthesis Mismatch as Determinants of Outcome After Isolated Aortic Valve Replacement

https://doi.org/10.1016/j.amjcard.2009.04.035Get rights and content

There are variable reported effects of patient-prosthesis mismatch (P-PM) on outcome. It was hypothesized that the adverse effect attributed to P-PM is actually due to left ventricular diastolic dysfunction (DD) in patients with small hearts. The aim of this study was therefore to determine the association among P-PM, DD, and outcomes. Doppler echocardiography was performed in 156 patients after aortic valve replacement. In vivo effective orifice areas for each prosthesis type and size were obtained from published references values of normally functioning prostheses. P-PM was identified from the predicted indexed orifice area, obtained by dividing the effective orifice area by body surface area. DD was classed as normal, delayed relaxation (prolonged deceleration time for age), or increased left atrial pressure (increased E/E′ ratio, left atrial enlargement, short deceleration time). Events (cardiac-related hospitalizations and all-cause mortality after aortic valve replacement) were determined over a median follow-up periods of 3.5 years (interquartile range 2.1 to 5.7). P-PM was found in 91 patients (58%). Of the patients with P-PM, no DD was present on postoperative echocardiography in 15 patients (16%), delayed relaxation in 35 (39%), and increased left atrial pressure in 41 (45%). There were 61 total events (18 deaths and 43 hospitalizations): 4 (7%) in the no-DD group, 26 (42%) in the delayed relaxation group, and 31 (51%) in the increased left atrial pressure group. DD (p = 0.034) but not age (p = 0.09), the left ventricular ejection fraction (p = 0.60), or the presence of mismatch (p = 0.20) was associated with events. In conclusion, P-PM was associated with 14% mortality and a 39% composite event rate over 2-year follow-up. Events were significantly associated with DD.

Section snippets

Methods

We studied 156 consecutive patients who had undergone AVR from 1998 to 2008 and undergone postoperative, clinically indicated follow-up echocardiography (Figure 1). Demographic variables and preoperative, operative, and postoperative clinical data were collected for each patient, including functional status, surgical risk, and prosthesis type and size. Clinical and investigation data were used to define surgical risk using the Euroscore.10

This study included patients who underwent AVR only, for

Results

Using the cutoff of ≤0.85 cm2/m2, we were able to identify 91 patients (58%) who had mismatch. Table 2 lists differences in demographic features between patients with and without P-PM, as well as a number of features that point to a small heart, including lower cardiac volumes and the use of bioprosthetic valves. However, there were no other differences in risk factors for outcomes, including cardiac function and surgical risk. P-PM occurred in 78 of the 115 patients (68%) who underwent AVR for

Discussion

The results of this study of outcomes in patients having postoperative echocardiograms was that P-PM was not predictive of death or total events over an intermediate follow-up period of 3 years. However, persisting DD was associated with P-PM, and events were significantly associated with the presence of DD, independent of P-PM. Survival was particularly decreased in patients with more severe classes of DD.

DD is almost universal in patients with aortic stenosis but usually improves with the

References (28)

Cited by (11)

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    Patient-prosthesis mismatch can contribute to persistent diastolic dysfunction due to elevated LV systolic pressure and limited regression of LV hypertrophy. It appears that diastolic dysfunction is one of the major mechanisms by which mismatch contributes to clinical events of death and hospitalizations in this setting (19). The diagnostic evaluation of these patients is geared toward identifying and grading the diastolic dysfunction as well as determining the potential underlying reasons.

  • Aortic stenosis

    2015, Learning Cardiac Auscultation: From Essentials to Expert Clinical Interpretation
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This study was supported in part by a program grant from the National Health and Medical Research Council, Canberra, Australia.

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