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The relevance of prosthesis–patient mismatch after aortic valve replacement

Nature Clinical Practice Cardiovascular Medicine volume 5, pages 764–765 (2008)Cite this article

The term valve prosthesis–patient mismatch (PPM) describes a state in which the effective orifice area (EOA) of a normally functioning heart valve prosthesis is too small in relation to the patient's body size; this situation results in high transvalvular pressure gradients.1 The EOA is a physiological parameter that represents the minimal cross-sectional area of the transprosthetic flow jet, and is easily measurable by Doppler echocardiography. The only parameter that has been validated to identify PPM is the indexed EOA: that is, the EOA of the prosthesis divided by the patient's body surface area.2 The rationale for using this parameter is that pressure gradients are essentially determined by EOA and transvalvular flow, which in turn are largely related to body size and resultant cardiac output requirements. For aortic valve prostheses, PPM is considered to be severe when the indexed EOA is less than 0.65 cm2/m2 and moderate when this value is between 0.65 cm2/m2 and 0.85 cm2/m2. PPM is classed as not clinically significant when the indexed EOA is greater than 0.85 cm2/m2. Severe PPM occurs in 2–11% of patients after aortic valve replacement (AVR), whereas the prevalence of moderate PPM among these individuals is 20%–70%.3

Strong evidence shows that patients with PPM have worse functional class and exercise capacity, reduced regression of left ventricular (LV) hypertrophy, inferior recovery of coronary flow reserve, impaired blood coagulation status, and more adverse cardiac events after AVR compared with patients without PPM.3,4 PPM is also associated with an increased risk of both perioperative5,6 and late mortality.4,6,7,8,9 The greatest mortality risk is observed in patients with pre-existing LV systolic dysfunction.5,7 The interaction between LV dysfunction and PPM is consistent with the concept that the increased LV afterload caused by PPM is less-well-tolerated in a poorly functioning ventricle than in a normal ventricle. Avoidance of PPM in patients with LV systolic dysfunction is, therefore, an important priority.

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Authors and Affiliations

  1. P Pibarot is Professor of Medicine and Director of the Canada Research Chair in Valvular Heart Diseases at Laval University and JG Dumesnil is Professor of Medicine and a Cardiologist at Laval University and Quebec Heart Institute, Québec City, QC, Canada.,

    Philippe Pibarot & Jean G Dumesnil

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  1. Philippe Pibarot
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  2. Jean G Dumesnil
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Correspondence to Philippe Pibarot.

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Competing interests

P Pibarot has received Speakers' Bureau honoraria from Edwards Lifesciences, Medtronic, Sorin, and St Jude Medical. He has also acted as a Consultant for Sorin and received research support from Edwards Lifesciences. JG Dumesnil received Speakers' Bureau honoraria from Medtronic and St Jude Medical.

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Pibarot, P., Dumesnil, J. The relevance of prosthesis–patient mismatch after aortic valve replacement. Nat Rev Cardiol 5, 764–765 (2008). https://doi.org/10.1038/ncpcardio1366

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