Structural: Focus on TAVR
Impact of Pre-Existing Prosthesis-Patient Mismatch on Survival Following Aortic Valve-in-Valve Procedures

https://doi.org/10.1016/j.jcin.2017.08.039Get rights and content
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Abstract

Objectives

The aim of this study was to determine whether the association of small label size of the surgical valve with increased mortality after transcatheter valve-in-valve (ViV) implantation is, at least in part, related to pre-existing prosthesis-patient mismatch (PPM) (i.e., a bioprosthesis that is too small in relation to body size).

Background

Transcatheter ViV implantation is an alternative for the treatment of patients with degenerated bioprostheses. Small label size of the surgical valve has been associated with increased mortality after ViV implantation.

Methods

Data from 1,168 patients included in the VIVID (Valve-in-Valve International Data) registry were analyzed. Pre-existing PPM of the surgical valve was determined using a reference value of effective orifice area for each given model and size of implanted prosthetic valve indexed for body surface area. Severe PPM was defined according to the criteria proposed by the Valve Academic Research Consortium 2: indexed effective orifice area <0.65 cm2/m2 if body mass index is <30 kg/m2 and <0.6 cm2/m2 if BMI is ≥30 kg/m2. The primary study endpoint was 1-year mortality.

Results

Among the 1,168 patients included in the registry, 89 (7.6%) had pre-existing severe PPM. Patients with severe PPM had higher 30-day (10.3%, p = 0.01) and 1-year (unadjusted: 28.6%, p < 0.001; adjusted: 19.3%, p = 0.03) mortality rates compared with patients with no severe PPM (4.3%, 11.9%, and 10.9%, respectively). After adjusting for surgical valve label size, Society of Thoracic Surgeons score, renal failure, diabetes, and stentless surgical valves, presence of pre-existing severe PPM was associated with increased risk for 1-year mortality (odds ratio: 1.88; 95% confidence interval: 1.07 to 3.28; p = 0.03). Patients with severe PPM also more frequently harbored high post-procedural gradients (mean gradient ≥20 mm Hg).

Conclusions

Pre-existing PPM of the failed surgical valve is strongly and independently associated with increased risk for mortality following ViV implantation.

Key Words

prosthesis-patient-mismatch
transcatheter aortic valve replacement
valve-in-valve

Abbreviations and Acronyms

AVR
aortic valve replacement
CI
confidence interval
EOA
effective orifice area
HR
hazard ratio
PPM
prosthesis-patient mismatch
STS
Society of Thoracic Surgeons
THV
transcatheter heart valve
ViV
valve-in-valve

Cited by (0)

Dr. Pibarot is the Canada Research Chair in Valvular Heart Disease; his research program is funded by the Canadian Institutes of Health Research (grant FDN-143225); and has received research grants from Edwards Lifesciences and Medtronic for echocardiography core laboratory analyses in transcatheter heart valves. Dr. Dvir is a consultant for Edwards Lifesciences, Medtronic, and St. Jude Medical. Dr. Moat has received consulting and speaking fees from Abbott, Edwards Lifesciences, and Medtronic. Dr. Latib is a consultant for Medtronic; has received speaking honoraria from Abbott Vascular; and research grants from Medtronic and Edwards Lifesciences. Dr. Kim is a proctor for Symetis and St. Jude Medical. Dr. Linke is a consultant for Medtronic, St. Jude Medical, Claret Medical, Boston Scientific, Edwards Lifesciences, Symetis, and Bard; and owns stock options in Claret Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.