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Editorial

Prosthesis-Patient Mismatch Following Aortic Valve Replacement: Finding Predictors for Prevention

The impact of prosthesis-patient mismatch

Nowadays, the main indication for valve surgery, in patients with anatomically important aortic valve disease, occurs at the onset of symptoms, given the presumed benefit of reduced morbidity and mortality associated with this procedure in this context.^– Thus, the presence of PPM following surgical implantation of an aortic bioprosthesis interferes in the expected reduction of symptomatology and mortality rates, thus minimizing the benefits that such invasive procedure could bring to the patient. Therefore, we need tools to predict the risk of PPM and thus implement strategies that can prevent such entity. This scenario was evaluated by Otto et al. in the current issue of the Arquivos Brasileiros de Cardiologia.

PPM is defined echocardiographically by an indexed effective orifice area (EOA) ≤ 0.85cm²/m² and considered severe if ≤ 0.65 cm²/m². Since this parameter is indexed by body surface area, individuals with body mass index ≥ 35 kg/m² have lower reference values (≤ 0.70 cm²/m² and ≤ 0.55 cm²/m², respectively) to avoid overestimation of anatomical severity in these patients. Its reported prevalence varies greatly: up to 70% in the case of moderate PPM and 20% in the case of severe PPM.

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Original Article

Determinants of Aortic Prosthesis Mismatch in a Brazilian Public Health System Hospital: Big Patients or Small Prosthesis?

Maria Estefania Otto et al. Fernando Antibas Atik Marcelo do Nascimento Moreira Luiz Carlos Madruga Ribeiro … Bianca Corrêa Rocha de Mello Joyce Gomes Elias Lima Maiara Sanchez Ribeiro Ana Carolina Pereira Matos Domingues Reyna Pinheiro Calzada Armindo Jreige Jr. Larissa Lucas Schloicka Philippe Pibarot

Abstract

Background:

Prosthesis-patient mismatch (PPM) is associated with worse outcomes.

Objective:

Determine the frequency and evaluate preoperatory variables independently associated with severe PPM in a tertiary hospital focused on Public Health Care.

Methods:

A total of 316 patients submitted to aortic valve replacement, who had echocardiography performed within the first 30 days after surgery, were retrospectively analyzed. The indexed effective orifice area (iEOA) of the prosthesis was used to classify the patients into three groups, according to PPM, considering body mass index (BMI): severe PPM (iEOA) < 0.65 cm²/m²), mild to moderate PPM (iEOA, 0.65 cm²/m² – 0.85 cm²/m²) and without PPM (iEOA > 0.85 cm²/m²) for a BMI < 30 kg/m² and severe PPM (iEOA) < 0.55 cm²/m²), mild to moderate (iEOA, 0.55 cm²/m²– 0.70 cm²/m²) and without PPM (iEOA > 0.7 cm²/m²) for a BMI > 30 kg/m². Statistical significance was considered when p < 0.05.

Results:

iEOA was obtained in 176 patients. The frequency of severe and moderate PPM was 33.4% and 36.2%, respectively. Severe PPM patients were younger and had larger BMI, but smaller left ventricular outflow tract diameter (LVOTD). The independent variables used to predict severe PPM were male gender, BMI > 25 kg/m², age < 60 years, LVOTD < 21 mm, and rheumatic etiology with an area under the ROC curve of 0.82.

Conclusion:

The frequency of severe PPM is high in a Brazilian population representative of the Public Health System, and it is possible to predict PPM from preoperative variables such as rheumatic valvular disease, gender, BMI, age and LVOTD.