This document discusses patient-prosthesis mismatch (PPM) after transcatheter aortic valve replacement (TAVR). It provides definitions of PPM levels based on effective orifice area indexed to body surface area (EOAi). Several studies are referenced that show severe PPM is associated with reduced survival, especially in patients with low ejection fraction. The document concludes that the best treatment is to avoid PPM by using valve sizes that match patient anatomy in order to maximize hemodynamic performance of the prosthetic valve.

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