Impact of prosthesis–patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement

doi:10.1016/j.ijcard.2013.07.116

International Journal of Cardiology

Volume 168, Issue 4, 9 October 2013, Pages 4150-4154

https://doi.org/10.1016/j.ijcard.2013.07.116 Get rights and content

Abstract

Background

Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR).

Aim of the present study is to evaluate the impact of mitral prosthesis–patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH).

Methods

A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi ≤ 1.2 cm²/m². Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP) > 40 mmHg. Clinical and echocardiographic follow-up (median 27 months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM.

Results

There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR ≥ 2 + (57%vs.22%; p = 0.0001), and PH (62%vs.24%;p < 0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p < 0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p < 0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p < 0.0001) and LV ejection fraction (p < 0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM.

Conclusions

This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.

Introduction

Previous studies reported that prosthesis–patient mismatch (PPM) is associated with worse hemodynamics, less regression of left ventricular hypertrophy, more cardiac events, and higher mortality rates after aortic valve replacement [1], [2], [3], [4]. However, PPM following mitral valve replacement (MVR) has been less investigated. Previous studies reported that mitral PPM is not uncommon, ranging between 30 and 85% when in vivo evaluation of effective orifice area (EOA) is performed [5], [6], [7]. Two studies reported that mitral PPM is independently associated with increased mortality [5], [6], whereas another one found no significant impact on survival [7]. Mitral PPM can be equated to residual mitral stenosis resulting in increased trans-mitral gradients, increased left atrial pressure, and pulmonary hypertension (PH). These factors may lead to right ventricular dilatation/dysfunction and to atrial fibrillation, which may, in turn, lead to tricuspid annulus dilatation and functional tricuspid regurgitation (fTR).

Indeed, tricuspid regurgitation is not uncommon in the settings of mitral valve disease. At least moderate fTR is present in more than one-third of patients presenting with mitral stenosis and in 15% of patients with mitral regurgitation [8]. Such patients are more likely to have NYHA functional class III or IV [9], and the persistence of fTR after MVR predicts poor outcome [10].

After earlier reports supporting conservative treatment of fTR [11], it was subsequently demonstrated that fTR might not resolve after isolated MVR [12], [13]. Several factors (age, pulmonary hypertension, atrial fibrillation, and tricuspid annular diameter) may hinder the postoperative improvement of fTR [14], [15]. Hence, current guidelines [16], [17] recommend tricuspid valve repair in patients undergoing mitral valve surgery in the presence of severe tricuspid regurgitation (class I), and in the presence of moderate TR or of dilated tricuspid annulus (class IIa/b).

The objective of this study was to investigate the impact of mitral PPM on fTR and pulmonary arterial hypertension following MVR.

Section snippets

Methods

This study was reviewed and approved by the Institutional Review Board of the University of Rome, and a waiver of consent was granted.

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology.

Perioperative analysis

A total of 210 patients undergoing isolated MVR were investigated and 101/210 (48%) of those had fTR = 2 + not addressed at surgery. Overall, 88/210 (42%) patients developed mitral PPM but none had prosthetic valve dysfunction. As expected, prosthesis–patient mismatch resulted in significant differences in both mean EOAi (0.93 ± 0.08 vs. 1.28 ± 0.07 cm²/m² for patients with or without PPM, respectively; p < 0.0001), and mean mitral trans-prosthetic gradients (4.7 ± 1.1 vs. 3.2 ± 2.5 mmHg for patients with or

Main findings

The main finding of this study was that mitral PPM is associated with lesser regression of both fTR and PH following isolated MVR. These associations were independent of other preoperative and operative variables. In addition, patients with PPM also exhibited less improvement in NYHA functional class, thus further emphasising the clinical relevance of these results. There were no significant differences with regards to mortality between PPM and no-PPM groups, but it has to be pointed out that

Conclusion

The results of the present study suggest that mitral PPM may hinder the regression of both fTR and PH in patients undergoing isolated MVR. This negative effect was also associated with worse functional capacity. These findings provide a strong impetus for the application of preventive strategies at the time of operation to avoid PPM or reduce it severity and for the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.

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Cited by (23)

Impact of Periprocedural Pulmonary Hypertension on Outcomes After Transcatheter Aortic Valve Replacement
2022, Journal of the American College of Cardiology
There are limited data on the prognostic impact of periprocedural pulmonary hypertension (PH) after transcatheter aortic valve replacement (TAVR).
The aim of this study was to investigate the prognostic impact of normalized, new-onset, and residual PH after TAVR.
The OCEAN-TAVI (Optimized Transcatheter Valvular Intervention–Transcatheter Aortic Valve Implantation) registry is an ongoing, multicenter Japanese registry that includes 2,588 patients who underwent TAVR. Patients were classified into 4 groups according to periprocedural systolic pulmonary artery pressure by echocardiography: no PH before and after TAVR (no PH), PH before but not after TAVR (normalized PH), PH after but not before TAVR (new-onset PH), and PH before and after TAVR (residual PH). A systolic pulmonary artery pressure cutoff of >36 mm Hg was applied for PH. The primary endpoint was all-cause mortality at 2 years. Logistic regression analysis was used to identify clinical predictors of residual and new-onset PH.
In total, 1,872 patients were divided into 4 groups: 1,027 (54.9%) in the no PH group, 257 (13.7%) in the normalized PH group, 280 (15.0%) in the new-onset PH group, and 308 (16.5%) in the residual PH group. There was a significant difference in all-cause mortality among the 4 groups at 2 years (11.0%, 12.8%, 18.6%, and 24.7%, respectively; P < 0.01). Among 565 patients who had preprocedural PH, 257 (45.5%) experienced normalization of PH, with mortality comparable with that in the no PH group. In multivariable logistic regression analysis, predictors of residual PH after TAVR were atrial fibrillation and baseline tricuspid regurgitation moderate or greater, whereas prosthesis-patient mismatch was a predictor of new-onset PH.
Risk stratification on the basis of post-TAVR PH status can identify patients at increased mortality after TAVR. Prosthesis-patient mismatch was identified as a novel predictor of new-onset PH. (Optimized Transcatheter Valvular Intervention-Transcatheter Aortic Valve Implantation [OCEAN-TAVI]; UMIN000020423)
Prosthesis-patient mismatch following aortic and mitral valves replacement – A comprehensive review
2022, Progress in Cardiovascular Diseases
Prothesis-patient mismatch (PPM) occurs when there is a mismatch between the effective orifice area (EOA) of the prosthetic valve and the required cardiac output to meet the need of the patient's body surface area (BSA). The clinical threshold for PPM occurs when the indexed effective orifice area (iEOA) is ≤0.65 cm²/m² for the aortic valve prosthesis, and ≤ 1.20 cm²/m² for the mitral valve prosthesis. The wide variation of reported incidence of PPM is most likely attributed to the variation in the methods of calculating iEOA [(for e.g., using continuity equation across the prosthesis versus using projected EOA (generated by the industry)]. Newer generation mechanical valves have shown less PPM than older generation, and stentless bioprosthesis have less PPM than stented prosthesis.
Long-term clinical outcome of PPM is associated with adverse cardiovascular events especially in the presence of pre-existing left ventricle dysfunction or with concomitant procedure such as coronary artery bypass graft surgery. Strategies to mitigate the risk of PPM such as aortic root replacement in patients with the small aortic annulus should be utilized. Accurate assessment of the patient's annular size and indexing the effective orifice area (EOA) of the prosthesis to patient's BSA at the time of prosthesis implantation are important steps to preventing future PPM.
Aortic Valve Prosthesis-Patient Mismatch in a Patient Undergoing Redo Mitral Valve Replacement for Infective Endocarditis
2018, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Although the presented case pertains to PPM of the aortic valve, it is important to keep in mind that PPM can occur with prosthetic valves in the mitral, tricuspid, or pulmonic positions.49–51 Mitral valve PPM has been defined as an iEOA <1.2 cm2/m2.49–51 The development of PPM after mitral valve replacement can lead to persistent pulmonary hypertension, significant tricuspid regurgitation, and reduced survival.49–51
Predictors and Outcomes of Prosthesis-Patient Mismatch After Aortic Valve Replacement
2016, JACC: Cardiovascular Imaging
Citation Excerpt :
This may be explained by the fact that once LV function and hemodynamics have stabilized following the early post-AVR period, the impact of a moderate PPM on subsequent outcome is less important. The increased risk of late mortality associated with severe PPM may be related to: 1) the persistence of LV hypertrophy and impaired coronary flow reserve and/or the persistence/recurrence of heart failure due to the residual LV afterload related to PPM (34,35); 2) the persistence of concomitant untreated mitral and tricuspid regurgitation (36,37); and 3) the accelerated structural degeneration of bioprosthetic valves (38,39). In contrast to what was observed for perioperative mortality, the impact of PPM on overall mortality was similar in younger versus older patients.
This study sought to evaluate predictors of prosthesis-patient mismatch (PPM) and its association with the risk of perioperative and overall mortality.
PPM is associated with increased mid- and long-term mortality after surgical aortic valve replacement. Conflicting results have been reported with regard to its association with perioperative mortality.
Databases were searched for studies published between 1965 and 2014. Main outcomes of interest were perioperative mortality and overall mortality.
The search yielded 382 studies for inclusion. Of these, 58 articles were analyzed and their data extracted. The total number of patients included was 40,381 (39,568 surgical aortic valve replacement and 813 transcatheter aortic valve replacement). Perioperative (odds ratio: 1.54; 95% confidence interval: 1.25 to 1.91) and overall (i.e., perioperative and post-operative) mortality (hazard ratio: 1.26; 95% confidence interval: 1.16 to 1.36) was increased in patients with PPM. The impact of PPM on mortality was higher in those studies in which the mean age of the patients was <70 years of age (and/or AVR with associated coronary artery bypass graft was included). Severe PPM was associated with increased risk of both perioperative and overall mortality, whereas moderate PPM was associated with increased risk of perioperative mortality but not of overall mortality. The impact of PPM was less pronounced in patients with larger body mass index (>28 kg/m²) compared with those with lower index. Predictors of PPM were older age, female sex, hypertension, diabetes, renal failure, larger body surface area, larger body mass index, and the utilization of a bioprosthesis.
PPM increases perioperative and overall mortality proportionally to its severity. The identification of predictors for PPM may be useful to identify patients who are at higher risk for PPM. The findings of this study support the implementation of strategies to prevent PPM especially in patients <70 years of age and/or with concomitant coronary artery bypass graft.
Prosthesis–patient mismatch due to small ring annuloplasty in patients with degenerative mitral insufficiency
2016, Journal of Cardiology
Avoidance of prosthesis–patient mismatch (PPM) is important when selecting a mitral valve prosthesis. This study investigated the effect of PPM after small ring mitral valve annuloplasty on postoperative hemodynamics and the clinical course.
This study retrospectively reviewed 227 patients with symptomatic severe mitral insufficiency (MI) who underwent mitral valve repair for degenerative MI using an Edwards ring or band (size: 26–32 mm) between 2003 and 2012. Echocardiography was performed postoperatively and at follow-up to evaluate cardiac function, including residual MI, mean transmitral pressure gradient, left atrial diameter (LAD), and tricuspid regurgitant pressure gradient (TRPG).
There were no operative deaths. Actuarial freedom from major adverse cardiac events was 91% at 10 years. The postoperative MI grade was not significantly different between different sizes of prosthesis (26 mm, 0.67 ± 0.8; 28 mm, 0.73 ± 0.9; 30 mm, 0.85 ± 0.9; 32 mm, 0.3 ± 0.6). LAD and TRPG were significantly lower for each size of prosthesis at follow-up (all p < 0.05). Patients with a smaller body surface area received a significantly smaller prosthesis (p < 0.05). The transmitral pressure gradient was significantly higher in patients with a 26-mm prosthesis than in patients with a larger size of prosthesis. Thirty-three patients had a follow-up transmitral pressure gradient ≥5 mmHg. The follow-up LAD was larger in patients with a transmitral pressure gradient <5 mmHg than in patients with that ≥5 mmHg (43.2 ± 9.4 mm vs 47.1 ± 9.6 mm, p < 0.05).
Mitral valve repair results in excellent clinical outcomes with significant reductions in MI, LAD, and TRPG for all sizes of prosthesis. However, use of a smaller prosthesis may result in a higher mean transmitral pressure gradient, and may inhibit reverse remodeling of the left atrium. Therefore, PPM should be avoided.
Patient-Prosthesis Mismatch After Mitral Valve Replacement: A Propensity Score Analysis
2016, Annals of Thoracic Surgery
Citation Excerpt :
They demonstrated that 71% of 56 patients had mitral PPM, and there was a significant correlation between pulmonary artery pressure and EOAI. In another study [23], Angeloni and colleagues showed that prevalence of functional tricuspid regurgitation greater than grade 2 and pulmonary hypertension (systolic pulmonary artery pressure greater than 40 mm Hg) were significantly higher in patients with PPM compared with patients not having PPM (57% versus 22%, and 62% versus 24%, respectively). However, we could not evaluate those results because not all patients underwent follow-up echocardiography, and it was irregularly performed at the discretion of the operating surgeon or the referring physician.
We evaluated the impact of patient-prosthesis mismatch (PPM) after mitral valve replacement on the clinical outcomes using propensity score models.
In all, 760 patients (aged 51 ± 12 years; male:female = 252:508) in whom mitral valve replacement was performed using three types of mechanical valves and two types of bioprosthetic valves were enrolled. In vivo data of effective orifice area was drawn from literatures and mitral PPM was defined as an effective orifice area index 1.2 cm²/m² or less. The propensity score model was used in two ways: the inverse probability of treatment weighting-adjusted multivariable analyses, and 1:1 propensity score matching. The duration of the follow-up was 127 months (range, 1 to 276).
Mitral PPM was identified in 19.3%. The patients with PPM (PPM group, n = 147) were older and had more comorbidities than the patients without PPM (non-PPM group, n = 613). The 10-year and 20-year overall survival and freedom from cardiac death were 83.5% and 71.3%, respectively, for the PPM group; and 90.2% and 83.1%, respectively, for the non-PPM group. The inverse probability of treatment weighting-adjusted multivariable analyses demonstrated that mitral PPM is a significant risk factor for overall survival (hazard ratio 1.681, 95% confidence interval: 1.139 to 2.482) and freedom from cardiac death (hazard ratio 1.673, 95% confidence interval: 1.012 to 2.765). The propensity score matching extracted 68 pairs. Both overall survival and freedom from cardiac death were also higher in the propensity score-matched non-PPM group than in the PPM group (p = 0.039 and p = 0.017, respectively).
Mitral PPM significantly affects long-term outcomes after mitral valve replacement in terms of long-term survival and freedom from cardiac death.

View all citing articles on Scopus

^☆: Dr. Pibarot received research grants from Edwards Lifesciences LLC (Irvine, CA) and Medtronic Inc. (Minneapolis, MN). Other authors have nothing to disclose.

¹: This author takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

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Impact of prosthesis–patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement☆

Abstract

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Perioperative analysis

Main findings

Conclusion

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Chest

Am Heart J

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Am Soc Echocardiogr

Ann Thorac Surg

Ann Thorac Surg

Am Heart J

The relevance of prosthesis–patient mismatch after aortic valve replacement

Nat Clin Pract Cardiovasc Med

Impact of prosthesis–patient mismatch on the regression of secondary mitral regurgitation after isolated aortic valve replacement with a bioprosthetic valve in patients with severe aortic stenosis

Circ Cardiovasc Imaging