Impact of prosthesis-patient mismatch on long-term survival in patients with small St Jude medical mechanical prostheses in the aortic position

Article

关键词: LEFT-VENTRICULAR MASS;    VALVE-REPLACEMENT;    PATCH ENLARGEMENT;    HEART-VALVE;    FOLLOW-UP;    SIZE;    ANNULUS;    MORBIDITY;    MORTALITY;    DEATH;   

DOI  :  10.1161/CIRCULATIONAHA.105.546754

来源: SCIE

【 摘 要 】

Background - The impact of aortic prosthesis-patient mismatch (P-PtM) on long-term survival is unclear. Methods and Results - Between 1985 and 2000, 388 patients at Mayo Clinic in Rochester, Minn, underwent aortic valve replacement (AVR) with 19- or 21-mm St Jude Medical prostheses and had transthoracic echocardiography within 1 year after AVR. Mean age of patients was 62 +/- 13 years; 69% were female. Prosthesis effective orifice area (EOA) was derived from the continuity equation. P-PtM was classified as severe (indexed EOA <= 0.60 cm(2)/m(2)), moderate (0.60 cm(2)/m(2) < indexed EOA <= 0.85 cm(2)/m(2)), or not hemodynamically significant indexed EOA >0.85 cm(2)/m(2)). P-PtM was severe in 66 patients 17%), moderate in 168 43%), and not hemodynamically significant in 154 40%). Patients with severe P-PtM had a significantly larger body surface area P < 0.0001), higher mean gradient P < 0.0001), lower preoperative P < 0.0001) and postoperative P < 0.0001) ejection fractions, and lower stroke volume P < 0.0001) and more often received a 19-mm prosthesis P = 0.0008) than patients with moderate or no hemodynamically significant mismatch. For patients with severe mismatch, 5-year survival rates 72 +/- 6%) and 8-year survival rates 41 +/- 8%) were significantly less than for patients with moderate mismatch 80 +/- 3% and 65 +/- 5%; P = 0.026) or no hemodynamically significant mismatch 85 +/- 3% and 74 +/- 5%; P = 0.002). On multivariate analysis after adjustment for other predictors of outcome, severe mismatch was associated with higher mortality hazard ratio 2.18; 95% confidence interval 1.24 to 3.85; P = 0.007) and higher incidence of congestive heart failure hazard ratio 3.1; 95% confidence interval 1.3 to 7.4; P = 0.009) than no hemodynamically significant mismatch. Conclusions - Severe P-PtM is an independent predictor of higher long-term mortality and congestive heart failure in patients with small St Jude Medical aortic valve prostheses. For patients undergoing AVR who are at risk of severe mismatch, every effort should be made to use a larger prosthesis or to consider a prosthesis with a larger EOA.

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