Author + information
- Received July 30, 2018
- Revision received October 1, 2018
- Accepted October 3, 2018
- Published online January 7, 2019.
- Philippe Pibarot, DVM, PhDa,∗ (, )
- Julien Magne, PhDb,c,
- Jonathon Leipsic, MDd,
- Nancy Côté, PhDa,
- Philippe Blanke, MDd,
- Vinod H. Thourani, MDe and
- Rebecca Hahn, MDf
- aDepartment of Cardiology, Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
- bService Cardiologie, Hôpital Dupuytren, CHU Limoges, Limoges, France
- cINSERM 1094, Limoges, France
- dDepartment of Radiology, University of British Columbia and St. Paul’s Hospital, Vancouver, Canada
- eDepartment of Cardiology, MedStar Heart and Vascular Institute and Georgetown University, Washington, DC
- fDepartment of Cardiology, Columbia University Medical Center, New York, New York
- ↵∗Address for correspondence:
Dr. Philippe Pibarot, Institut Universitaire de Cardiologie et de Pneumologie de Québec, 2725 Chemin Sainte-Foy, Québec City, Québec G1V 4G5, Canada.
Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthetic valve is too small in relation to a patient’s body size, thus resulting in high residual postoperative pressure gradients across the prosthesis. Severe PPM occurs in 2% to 20% of patients undergoing surgical aortic valve replacement (AVR) and is associated with 1.5- to 2.0-fold increase in the risk of mortality and heart failure rehospitalization. The purpose of this article is to present an overview of the role of multimodality imaging in the assessment, prediction, prevention, and management of PPM following AVR. The risk of PPM can be anticipated at the time of AVR by calculating the predicted indexed from the normal reference value of EOA of the selected prosthesis and patient’s body surface area. The strategies to prevent PPM at the time of surgical AVR include: 1) implanting a newer generation of prosthetic valve with better hemodynamic; 2) enlarging the aortic root or annulus to accommodate a larger prosthetic valve; or 3) performing TAVR rather than surgical AVR. The identification and quantitation of PPM as well as its distinction versus prosthetic valve stenosis is primarily based on transthoracic echocardiography, but important information may be obtained from other imaging modalities such as transesophageal echocardiography and multidetector computed tomography. PPM is characterized by high transprosthetic velocity and gradients, normal EOA, small indexed EOA, and normal leaflet morphology and mobility. Transesophageal echocardiography and multidetector computed tomography are particularly helpful to assess prosthetic valve leaflet morphology and mobility, which is a cornerstone of the differential diagnosis between PPM and pathologic valve obstruction. Severe symptomatic PPM following AVR with a bioprosthetic valve may be treated by redo surgery or the transcatheter valve-in-valve procedure with fracturing of the surgical valve stent.
- aortic valve replacement
- Doppler echocardiography
- multidetector computed tomography
- prosthesis-patient mismatch
Dr. Pibarot is the Canada Research Chair in Valvular Heart Disease, and is funded by a Foundation Grant (FDN-143225) from Canadian Institutes of Health research, Ottawa, Ontario, Canada. Drs. Pibarot and Hahn have received funding from Edwards Lifesciences and Medtronic for echocardiography core laboratory analyses in the context transcatheter valve therapy trials with no direct compensation. Dr. Leipsic has served as a consultant for and owns stock options in Circle Cardiovascular Imaging; and has worked in the core lab for Edwards Lifesciences and Medtronic. Drs. Leipsic and Blanke have received funding from Edwards Lifesciences for computed tomography laboratory analyses in the context transcatheter valve therapy trials with no direct compensation. Dr. Blanke has served as a consultant for Tendyne, Neovasc, and Circle Cardiovascular Imaging. Dr. Thourani is a consultant for Abbott Vascular, Boston Scientific, Edwards Lifesciences, Gore Vascular, and Jenavalve. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 30, 2018.
- Revision received October 1, 2018.
- Accepted October 3, 2018.
- 2019 American College of Cardiology Foundation
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