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CLINICAL RESEARCH: VALVULAR HEART DISEASE

Impact of Prosthesis-Patient Mismatch on Long-Term Survival After Aortic Valve Replacement

Influence of Age, Obesity, and Left Ventricular Dysfunction

Dania Mohty, MD, PhD^_*,, Jean G. Dumesnil, MD, FRCPC, FACC^_*, Najmeddine Echahidi, MD^_*, Patrick Mathieu, MD, FRCS^_*, François Dagenais, MD, FRCS^_*, Pierre Voisine, MD, FRCS^_* and Philippe Pibarot, DVM, PhD, FACC, FAHA^_*,_*

^_* Laval Hospital Research Center/Québec Heart Institute, Laval University, Québec, Québec, Canada
Université François Rabelais, Faculté de Médecine, Tours, France

Manuscript received March 28, 2008; revised manuscript received August 25, 2008, accepted September 15, 2008.

^_* Reprint requests and correspondence: Dr. Philippe Pibarot, Laval Hospital, 2725 Chemin Sainte-Foy, Québec, Québec G1V-4G5, Canada (Email: philippe.pibarot{at}med.ulaval.ca).

Objectives: This study was designed to evaluate the effect of valve prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) and to determine if this effect is modulated by patient age, body mass index (BMI), and pre-operative left ventricular (LV) function.

Background: We recently reported that PPM is an independent predictor of operative mortality after AVR, particularly when associated with LV dysfunction.

Methods: The indexed valve effective orifice area (EOA) was estimated in 2,576 patients having survived AVR and was used to define PPM as not clinically significant if it was >0.85 cm²/m², as moderate if >0.65 and 0.85 cm²/m², and severe if 0.65 cm²/m².

Results: After adjustment for other risk factors, severe PPM was associated with increased late overall mortality (hazard ratio [HR]: 1.38; p = 0.03) and cardiovascular mortality (HR: 1.63; p = 0.0006) in the whole cohort. Severe PPM was also associated with increased overall mortality in patients <70 years old (HR: 1.77; p = 0.002) and in patients with a BMI <30 kg/m² (HR: 2.1; p = 0.006), but had no impact in older patients or in obese patients. Moderate PPM was a predictor of mortality in patients with LV ejection fraction <50% (HR: 1.21; p = 0.01), but not in patients with preserved LV function.

Conclusions: Moderate PPM is associated with increased late mortality in patients with LV dysfunction, but with normal prognosis in those with preserved LV function. Notwithstanding the previously demonstrated deleterious effect of severe PPM on early mortality, this factor appears to increase late mortality only in patients <70 years old and/or with a BMI <30 kg/m² or an LV ejection fraction <50%.

Key Words: aortic valve • heart valve prostheses • mortality • hemodynamics

Abbreviations and Acronyms   AVR = aortic valve replacement   BMI = body mass index   BSA = body surface area   CABG = coronary artery bypass graft   CI = confidence interval   EOA = effective orifice area   HR = hazard ratio   LV = left ventricular   LVEF = left ventricular ejection fraction   PPM = valve prosthesis-patient mismatch

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