patient –prosthesis mismatch · patient –prosthesis mismatch vera h. rigolin, md, fase...
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Patient –Prosthesis Mismatch
Vera H. Rigolin, MD, FASEVice-President, American Society of Echocardiography
Professor of MedicineNorthwestern University
Bluhm Cardiovascular InstituteMedical Director, Echocardiography Laboratory
Northwestern Memorial HospitalChicago, IL USA
No Disclosures
Circulation 1978; 58: 20-4
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
“Le maladie du Pibarot”
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Methods to Calculate PPM
• EOAi calculated by echo using the continuity equation
– Normal: >0.85 cm2/m2– Moderate: 0.6-0.85 cm2/m2– Severe: <0.6 cm2/m2
• Manufactures’ charts• ASE Guidelines
– Peak velocity, mean gradient, AT, EOAi
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014
ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014
ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014
ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014
History
• 75 yr old female with symptomatic aortic stenosis.
• Underwent AVR with a 21 mm Edwards Pericardial Magna Valve
• Ht: 5’6.5”• Wt: 188 lbs• BSA: 1.96 m2• BMI:29.9
Echo Post op
PV= 3.2 m/secMean Grad=23 mmHgDVI=0.33EOA=1.0 cm2EOAi=0.5 cm2AT=90 msecSV=75 ml
Manufacturer’s table
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Effect of EOAi on Survival
Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Survival According to LVEF
Jamieson et al. Ann Thorac Surg 2010; 89: 51-9
• 1982-2003• 3,343 patients ( 2493 bio – (CE Perimount 667) and 850 MP)• Projected EOA• F/u 6.2 ± 5 yrs
Jamieson et al. Ann Thorac Surg 2010; 89: 51-9
Jamieson et al. Ann Thorac Surg 2010; 89: 51-9
• Moderate PPM 52%
• Severe PPM 27%
Florath et al. Am Heart J 2008; 155: 1135-42
Florath et al. Am Heart J 2008; 155: 1135-42
Mohty-Echahidi et al. Circ 2006; 113: 420-6
• 1985-2000• 388 patients who underwent St. Jude AVR• Echo within 1 yr after AVR• Severe PPM EOAI < 0.6 cm/m2, Mod 0.6-0.85 cm/m2,
Normal > 0.85 cm/m2)• Severe 66 ( 17%), Moderate 168 ( 43%), normal ( 40%)
Mohty-Echahidi et al. Circ 2006; 113: 420-6
Mohty-Echahidi et al. Circ 2006; 113: 420-6
Mohty-Echahidi et al. Circ 2006; 113: 420-6
• 571 pts who had a bioprosthetic AVR• 1/2005- 12/2008• 146( 26%) were included in this study• Inclusion:• Normal LVEF• Baseline and follow up echo at least 6 months after the date of
surgery• PPM assessed with 1) ASE methods, 2) manufacturer’s table, and
3) measured EOAiChacko et al. Circ Img 2013; 6: 776-83
Chacko et al. Circ Img 2013; 6: 776-83
Chacko et al. Circ Img 2013; 6: 776-83
Treatment
• Avoid severe PPM–Enlarge aortic root–Use stentless valve or other low
profile prosthesis• May tolerate mild to mod PPM in
an older/sedentary patient• Females and large BSA at most risk
Summary
• Various methods to calculate PPM • Echo-derived EOAi is dependent on
accurate measurements• Severe PPM may impact survival• Pts with low EF most vulnerable • Avoidance of PPM is the best
treatment
Thank You