patient prosthesis mismatch
TRANSCRIPT
Factors Affecting Survival After Mitral Valve Replacement in Patients
With ProsthesisndashPatient Mismatch
Presenter- Dr JYOTINDRA SINGH
INTRODUCTION
GOA for any given bioprosthetic
valve is here defined as the area of
the valve at its greatest opening
This is a valid approximation
because the GOA of a bioprosthetic
heart valve changes little during
systole
2
BACKGROUNDObviously the best way to avoid PPM
in the mitral position would be to repair
rather than to replace the valve
Unfortunately the options for
preventing PPM in the mitral position
are much more limited than in the
aortic position
In particular no alternative technique
exists to implant a larger prosthesis
and the implantation of a homograft or
of a stentless prosthesis is technically
more demanding and associated with
poor long-term durability
Hence the preventive strategy can be
oriented only toward the implantation
of a prosthesis having a larger EOA for
a given annulus size
PATHOPHYSIOLOGYHence PPM in the mitral position can be equated to residual mitral stenosis with
similar consequences (ie the persistence of abnormally high mitral gradients and
increased left atrial and pulmonary arterial pressures)
The major consequence of pulmonary hypertension is right ventricular failure
which generally results from chronic pressure overload and associated volume
overload with the development of tricuspid regurgitation
The persistence of high left atrial pressures may predispose to atrial fibrillation
This arrhythmia may compromise cardiac output and increase the incidence of
thromboembolic complications
The passive elevation in pulmonary capillary pressure caused by elevated left atrial
pressure also may lead to the development of pulmonary edema
Consistently Masuda et al found that the maximum transprosthetic flow velocity is a
strong determinantof the pulmonary capillary wedge pressure in children with
mitral prostheses
OBJECTIVE
Objective -The purpose of the current investigation was to
identify patient subgroups in which PPM most influenced outcome
after MVR specifically examining the impact of patient age and
prosthesis type on long-term survival
Place of study- Division of Cardiothoracic Surgery
Washington University School of Medicine St Louis Missouri
Period of study- (May 1992 to June 2008)
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
INTRODUCTION
GOA for any given bioprosthetic
valve is here defined as the area of
the valve at its greatest opening
This is a valid approximation
because the GOA of a bioprosthetic
heart valve changes little during
systole
2
BACKGROUNDObviously the best way to avoid PPM
in the mitral position would be to repair
rather than to replace the valve
Unfortunately the options for
preventing PPM in the mitral position
are much more limited than in the
aortic position
In particular no alternative technique
exists to implant a larger prosthesis
and the implantation of a homograft or
of a stentless prosthesis is technically
more demanding and associated with
poor long-term durability
Hence the preventive strategy can be
oriented only toward the implantation
of a prosthesis having a larger EOA for
a given annulus size
PATHOPHYSIOLOGYHence PPM in the mitral position can be equated to residual mitral stenosis with
similar consequences (ie the persistence of abnormally high mitral gradients and
increased left atrial and pulmonary arterial pressures)
The major consequence of pulmonary hypertension is right ventricular failure
which generally results from chronic pressure overload and associated volume
overload with the development of tricuspid regurgitation
The persistence of high left atrial pressures may predispose to atrial fibrillation
This arrhythmia may compromise cardiac output and increase the incidence of
thromboembolic complications
The passive elevation in pulmonary capillary pressure caused by elevated left atrial
pressure also may lead to the development of pulmonary edema
Consistently Masuda et al found that the maximum transprosthetic flow velocity is a
strong determinantof the pulmonary capillary wedge pressure in children with
mitral prostheses
OBJECTIVE
Objective -The purpose of the current investigation was to
identify patient subgroups in which PPM most influenced outcome
after MVR specifically examining the impact of patient age and
prosthesis type on long-term survival
Place of study- Division of Cardiothoracic Surgery
Washington University School of Medicine St Louis Missouri
Period of study- (May 1992 to June 2008)
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
GOA for any given bioprosthetic
valve is here defined as the area of
the valve at its greatest opening
This is a valid approximation
because the GOA of a bioprosthetic
heart valve changes little during
systole
2
BACKGROUNDObviously the best way to avoid PPM
in the mitral position would be to repair
rather than to replace the valve
Unfortunately the options for
preventing PPM in the mitral position
are much more limited than in the
aortic position
In particular no alternative technique
exists to implant a larger prosthesis
and the implantation of a homograft or
of a stentless prosthesis is technically
more demanding and associated with
poor long-term durability
Hence the preventive strategy can be
oriented only toward the implantation
of a prosthesis having a larger EOA for
a given annulus size
PATHOPHYSIOLOGYHence PPM in the mitral position can be equated to residual mitral stenosis with
similar consequences (ie the persistence of abnormally high mitral gradients and
increased left atrial and pulmonary arterial pressures)
The major consequence of pulmonary hypertension is right ventricular failure
which generally results from chronic pressure overload and associated volume
overload with the development of tricuspid regurgitation
The persistence of high left atrial pressures may predispose to atrial fibrillation
This arrhythmia may compromise cardiac output and increase the incidence of
thromboembolic complications
The passive elevation in pulmonary capillary pressure caused by elevated left atrial
pressure also may lead to the development of pulmonary edema
Consistently Masuda et al found that the maximum transprosthetic flow velocity is a
strong determinantof the pulmonary capillary wedge pressure in children with
mitral prostheses
OBJECTIVE
Objective -The purpose of the current investigation was to
identify patient subgroups in which PPM most influenced outcome
after MVR specifically examining the impact of patient age and
prosthesis type on long-term survival
Place of study- Division of Cardiothoracic Surgery
Washington University School of Medicine St Louis Missouri
Period of study- (May 1992 to June 2008)
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
2
BACKGROUNDObviously the best way to avoid PPM
in the mitral position would be to repair
rather than to replace the valve
Unfortunately the options for
preventing PPM in the mitral position
are much more limited than in the
aortic position
In particular no alternative technique
exists to implant a larger prosthesis
and the implantation of a homograft or
of a stentless prosthesis is technically
more demanding and associated with
poor long-term durability
Hence the preventive strategy can be
oriented only toward the implantation
of a prosthesis having a larger EOA for
a given annulus size
PATHOPHYSIOLOGYHence PPM in the mitral position can be equated to residual mitral stenosis with
similar consequences (ie the persistence of abnormally high mitral gradients and
increased left atrial and pulmonary arterial pressures)
The major consequence of pulmonary hypertension is right ventricular failure
which generally results from chronic pressure overload and associated volume
overload with the development of tricuspid regurgitation
The persistence of high left atrial pressures may predispose to atrial fibrillation
This arrhythmia may compromise cardiac output and increase the incidence of
thromboembolic complications
The passive elevation in pulmonary capillary pressure caused by elevated left atrial
pressure also may lead to the development of pulmonary edema
Consistently Masuda et al found that the maximum transprosthetic flow velocity is a
strong determinantof the pulmonary capillary wedge pressure in children with
mitral prostheses
OBJECTIVE
Objective -The purpose of the current investigation was to
identify patient subgroups in which PPM most influenced outcome
after MVR specifically examining the impact of patient age and
prosthesis type on long-term survival
Place of study- Division of Cardiothoracic Surgery
Washington University School of Medicine St Louis Missouri
Period of study- (May 1992 to June 2008)
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
PATHOPHYSIOLOGYHence PPM in the mitral position can be equated to residual mitral stenosis with
similar consequences (ie the persistence of abnormally high mitral gradients and
increased left atrial and pulmonary arterial pressures)
The major consequence of pulmonary hypertension is right ventricular failure
which generally results from chronic pressure overload and associated volume
overload with the development of tricuspid regurgitation
The persistence of high left atrial pressures may predispose to atrial fibrillation
This arrhythmia may compromise cardiac output and increase the incidence of
thromboembolic complications
The passive elevation in pulmonary capillary pressure caused by elevated left atrial
pressure also may lead to the development of pulmonary edema
Consistently Masuda et al found that the maximum transprosthetic flow velocity is a
strong determinantof the pulmonary capillary wedge pressure in children with
mitral prostheses
OBJECTIVE
Objective -The purpose of the current investigation was to
identify patient subgroups in which PPM most influenced outcome
after MVR specifically examining the impact of patient age and
prosthesis type on long-term survival
Place of study- Division of Cardiothoracic Surgery
Washington University School of Medicine St Louis Missouri
Period of study- (May 1992 to June 2008)
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
OBJECTIVE
Objective -The purpose of the current investigation was to
identify patient subgroups in which PPM most influenced outcome
after MVR specifically examining the impact of patient age and
prosthesis type on long-term survival
Place of study- Division of Cardiothoracic Surgery
Washington University School of Medicine St Louis Missouri
Period of study- (May 1992 to June 2008)
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Materials amp Methods
0
50
100
150
200
250
300
350
400
450
500
MEN WOMEN
460
305
N=765
N=765
lt 65yrs
gt65yrs
395
370
AGE PROFILE
AGE PROFILE
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Patient profile
325
440
0
50
100
150
200
250
300
350
400
450
500
valve profile
valve profile
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Materials amp Methods
0
5
10
15
20
25
30
26
23
11
8
1
Concomitant surgery
0
10
20
30
40 37
27
18
11
7
Indication
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Valve profile
0
10
20
30
40
50
60
70
80
90
100
lt65 yrs gt65 yrs
76
38
24
62
bioprosthetic
mechanical
0
5
10
15
20
25
30
23 to 25mm
27 mm 29mm 31 to 33 mm
15
27
3028
Valve size used
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
PPM CRITERIA
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Type of valve implanted
appears normal
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
RESULTS- PPM EVALUATION
0
10
20
30
40
50
60
70
2
32
68
30
45
25
MECHANICAL
Bioprosthetic
0
5
10
15
20
25
30
35
40
45
50
14
37
49
Overall PPM
SEVERE
MODERATE
ABSENT
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Age based evaluation of PPMProsthesisndashpatient mismatch was less common with mechanical valves than with biomechanical
Moderate or severe PPM was more common in women and patients with endocarditis diabetes and chronic renal disease
Ejection fraction was similar among groups as was the percentage of patients with an ejection fraction of 035 or less
With mechanical valves the incidence of severe and moderate PPM was higher in younger
patients but with bioprosthetic valves the incidence of PPM was higher in older patients
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Independent predictors of Severe PPM1) Advanced age
2) Diabetes Mellitus
3) Chronic renal disease
4) Bioprosthetic valves
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Operative MortalityOverall mortality ndash 97765 127
Mortality varied with complexity of the procedure
Independent predictors -
Active endocarditis
chronic renal insufficiency
peripheral vascular disease
non rheumatic origin
concomitant CABG
urgent or emergent status
implantation of a bioprosthetic valve
Operative mortality was higher with
severe PPM (24) compared with moderatePPM (14 ) or absent PPM (8)
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
CT FINDINGS
appears normal
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
LATE SURVIVALOf the 668 operative survivors there were 265 late deaths
403 patients were alive at late follow-up
Independent predictors of late death
Advanced age
Earlier operative year
CRF
Peripheral vascular disease
Congestive heart failure
Nonrheumatic origin
Concomitant CABG
Lower BSA
more significant PPM (lower EOABSA)
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
PPM- AGE STRATIFIED( Mechanical Valve)
0
20
40
60
80
100
Without PPM
With PPM
8277
66 62
5 yrs
10 yrs
010203040506070
Without PPM
With PPM
63
4740
305 yrs
10 yrs
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
PPM ( Age stratified) ndash Bioprosthetic VALVE
0
10
20
30
40
50
60
Without PPM
With PPM
585148
42
5 yrs
10 yrs
0
5
10
15
20
25
30
35
40
45
Without PPM
With PPM
43
30
21
0
5yrs
10 yrs
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Comments
ldquoplatelet and fibrin deposition inflammation
granulation tissue and finally encapsulation
Longterm device fibrous encapsulation with
extension to adjacent tissues add to structural
stability
rdquo Bioprosthetic valves undergo morphological
changes of both the tissue material as well as
the supporting structures which may
contribute to VPndashPM
Fbrous sheath may also encapsulate the
supporting structure of the valve encroaching
on the PHV orifice and also possibly causing
valve leaflet or disk immobilization
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
confirm that the lesion is solitary
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
BIOPSY Vs RESECTION
confirm that the lesion is solitary
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
Impact of prosthesis-patient mismatch on tricuspid valve regurgitation
and pulmonary hypertension following mitral valve replacementAngeloni E Melina G Benedetto U Roscitano A Pibarot P
Sapienza University of Rome Department of Cardiac Surgery
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 EOAile12cm2m2 Pulmonary
hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP)gt40mmHg Clinical and echocardiographic follow-up (median
27months) was 100 completed A total of 88210 (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 fTRge2+ (57vs22 p=00001) and PH (62vs24plt00001) were significantly higher in patients with PPM On
multivariable regression analysis EOAi (plt00001) and preoperative left ventricular (LV) end-diastolic diameter (plt00001) were found to
be independently associated with fTR decrease after MVR In addition EOAi (plt00001) and LV ejection fraction (plt00001) 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
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
EOAi should be measured at 1 to 4 weeks or at hospital discharge to evaluate the
actual valve size that wasimplanted This should also be done at 6 to 12 months to
evaluate the severity of VPndashPM that will affect long-term outcomes
The grading of severity of VPndashPM should be similar to another common LV outflow
tract obstruction namelyvalvular AS
To assess the effects of VPndashPM on mortality the goal should be to determine by
multivariate analysis the role of VPndashPM on mortality due to cardiac causes
The primary goal should be not to prevent VPndashPM but rather to prevent severe VPndash
PM
Use of the EOAi as a continuous variable may help to define the level of severe
VPndashPM that results in increased mortality and this may occur at a critical level of
obstruction
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
3 STEP PROTOCOL
was elaborated by Pibarot and Dumesnil
1) calculate the BSA using the Dubois method
2) determine the minimum EOA required to ensure an EOAi of 12 cm m2 based on the
minimum required EOAi for a given patient
3) select the type and size of the valve greater or equal to the minimal EOA value obtained in step 2
Although annular size is never a problem with ischemic regurgitation for rheumatic patients with
mitral stenosis partial posterior leaflet resection with pseudochord placement to maintain 3 papillary-annular continuity may be an option to make room for a bigger prosthesis
In contrast patients with a heavily calcified restricted mitral annulus may be at the
mercy of valve selection unless one wishes to embark on a complex annular decalcificationprocedure
Oversizing the valve can lead to disastrous complications including disruption of the atrioventricular groove
