Patient prothesis mismatch evaluation

1. Patient –Prosthesis Mismatch
Vera H. Rigolin, MD, FASE
Vice-President, American Society of Echocardiography
Professor of Medicine
Northwestern University
Bluhm Cardiovascular Institute
Medical Director, Echocardiography Laboratory
Northwestern Memorial Hospital
Chicago, IL USA

2. No Disclosures

3. Circulation 1978; 58: 20-4

4. Pibarot and Dumesnil. Heart 2006; 92: 1022-9
“Le maladie du Pibarot”

5. Pibarot and Dumesnil. Heart 2006; 92: 1022-9

6. Pibarot and Dumesnil. Heart 2006; 92: 1022-9

7. Methods to Calculate PPM
• EOAi calculated by echo using the continuity
equation
– Normal: >0.85 cm2/m2
– Moderate: 0.6-0.85 cm2/m2
– Severe: <0.6 cm2/m2
• Manufactures’ charts
• ASE Guidelines
– Peak velocity, mean gradient, AT, EOAi

8. Pibarot and Dumesnil. Heart 2006; 92: 1022-9

9. Pibarot and Dumesnil. Heart 2006; 92: 1022-9

10. ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

11. ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

12. ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

13. ASE Prosthetic Valve Guidelines. JASE 2009; 22: 975-1014

14. History
• 75 yr old female with symptomatic
aortic stenosis.
• Underwent AVR with a 21 mm
Edwards Pericardial Magna Valve
• Ht: 5’6.5”
• Wt: 188 lbs
• BSA: 1.96 m2
• BMI:29.9

15. Echo Post op

17. PV= 3.2 m/sec
Mean Grad=23
mmHg
DVI=0.33
EOA=1.0 cm2
EOAi=0.5 cm2
AT=90 msec
SV=75 ml

18. Manufacturer’s table

19. Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Effect of EOAi on Survival

20. Pibarot and Dumesnil. Heart 2006; 92: 1022-9
Survival According to LVEF

21. Jamieson et al. Ann Thorac Surg 2010; 89: 51-9

22. • 1982-2003
• 3,343 patients ( 2493 bio – (CE Perimount 667) and 850 MP)
• Projected EOA
• F/u 6.2 ± 5 yrs
Jamieson et al. Ann Thorac Surg 2010; 89: 51-9

23. Jamieson et al. Ann Thorac Surg 2010; 89: 51-9

25. • Moderate PPM 52%
• Severe PPM 27%
Florath et al. Am Heart J 2008; 155: 1135-42

26. Florath et al. Am Heart J 2008; 155: 1135-42

27. Mohty-Echahidi et al. Circ 2006; 113: 420-6

28. • 1985-2000
• 388 patients who underwent St. Jude AVR
• Echo within 1 yr after AVR
• Severe PPM EOAI < 0.6 cm/m2, Mod 0.6-0.85 cm/m2,
Normal > 0.85 cm/m2)
• Severe 66 ( 17%), Moderate 168 ( 43%), normal ( 40%)
Mohty-Echahidi et al. Circ 2006; 113: 420-6

29. Mohty-Echahidi et al. Circ 2006; 113: 420-6

30. Mohty-Echahidi et al. Circ 2006; 113: 420-6

31. • 571 pts who had a bioprosthetic AVR
• 1/2005- 12/2008
• 146( 26%) were included in this study
• Inclusion:
• Normal LVEF
• Baseline and follow up echo at least 6 months after the date of
surgery
• PPM assessed with 1) ASE methods, 2) manufacturer’s table, and
3) measured EOAi
Chacko et al. Circ Img 2013; 6: 776-83

32. Chacko et al. Circ Img 2013; 6: 776-83

33. Chacko et al. Circ Img 2013; 6: 776-83

34. Treatment
• Avoid severe PPM
–Enlarge aortic root
–Use stentless valve or other low
profile prosthesis
• May tolerate mild to mod PPM in
an older/sedentary patient
• Females and large BSA at most risk

35. Summary
• Various methods to calculate PPM
• Echo-derived EOAi is dependent on
accurate measurements
• Severe PPM may impact survival
• Pts with low EF most vulnerable
• Avoidance of PPM is the best
treatment

36. Thank You