The Impact of Patient-Prosthesis Mismatch on Late Outcomes after Mitral Valve Replacement
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Objective:
The incidence of patient-prosthesis mismatch (PPM) after mitral valve replacement (MVR) and its effect on late outcomes have remained unclear. This study was conducted to determine the impact of PPM on late survival, recurrent heart failure (CHF) and residual pulmonary hypertension (PHTN) after MVR.
Methods: Between 1985 and 2005, 884 patients, mean age 63 ± 12 years, underwent MVR (657 mechanical, 227 bioprosthesis) using contemporary prostheses. Mean clinical and echocardiographic follow-up was 5.1 + 4.1 years (4344 patient-years). PPM was defined as IEOA < 1.22 cm2/m2. Parametric and non-parametric analyses were used to determine predictors of outcomes.
Results: The incidence of PPM was 13.8%. Poor late survival was predicted by low IEOA (<1.22cm2/m2) (P=.05), NYHA class 3 or 4 (P<.0001), elevated right ventricular pressure (RVP) (P<.0001), stroke (P=.001), older age (P=.003), CAD (P=.03) and use of a bioprosthesis (P=.03). Predictors of recurrent CHF included low IEOA (P=.002), low ejection fraction (P=.03), elevated residual mean mitral gradient (P=.02) and use of a bioprosthesis (P=.0008). Residual PHTN was associated with small mitral size (P=.03), elevated RVP (P<.0001), low ejection fraction (P=.02) and atrial fibrillation (P=.03); IEOA did not predict PHTN (P=.89). Survival for patients with PPM versus those without PPM at 1, 3, 5 and 10 years was respectively 91% vs 95%, 85% vs 90%, 78% vs 86% and 65% vs 75% (P=.05).
Conclusions: PPM after MVR is not as uncommon as previously anticipated. In this study, PPM was independently associated with decreased late survival, recurrence of CHF and residual PHTN. These findings highlight the importance of implanting a sufficiently large prosthesis in adult patients undergoing MVR in order to optimize clinical results.
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