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Eur J Cardiothorac Surg 2006;30:1
© 2006 Elsevier Science NL

Editorial

Is severe valve prosthesis-patient mismatch (VP-PM) associated with a higher mortality?

Shahbudin H. Rahimtoola a , b , *

a University of Southern California, 2025 Zonal Avenue, Los Angeles, CA 90033, USA
b Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC+USC Medical Center, Keck School of Medicine at USC, Los Angeles, CA, USA

* Corresponding author. Tel.: +1 323 226 7264; fax: +1 323 221 4428. (Email: rahimtoo{at}usc.edu).

Two papers in the current issue of the journal questioned whether valve prosthesis-patient mismatch (VP-PM) [1] is associated with an increased mortality and have come to different conclusions.

Howell et al. [2] have classified severe VP-PM as prosthetic aortic valve area (PHVA) <0.6 cm2/m2, which was determined at the time of valve implantation from the manufacturer's in vitro data. The survival (‘all-cause mortality’) was not significantly different at 3 and 5 years from the ‘reference group’ (PHVA ≥ 0.6 cm2/m2).

Walther et al. [3] have also classified PHVA from the manufacturer's effective office area. They have classified severe VP-PM as PHVA < 0.65 cm2/m2and moderate VP-PM as PHVA 0.65–0.85 cm2/m2. In their study, moderate VP-PM was ‘independently predictive for short-term and long-term mortality’.

Three recent studies have documented an increased mortality with VP-PM:

1. Moon et al. [4] have calculated VP-PM (PHVA < 0.75 cm2/m2) on the basis ‘published normal values’ of PHV and concluded that VP-PM had a negative impact on survival for young patients, patients of average-size and for large patients with mechanical valves.
2. In a preliminary report, Mohan et al. [5] have shown that severe VP-PM (PHVA < 0.65 cm2/m2) was associated with a poorer survival.
3. Mohty-Echahidi et al. [6] showed that severe VP-PM (PHVA ≤ 0.60 cm2/m2) was associated with lower survival (from all-cause mortality) than those with moderate or ‘mild’ VP-PM. VP-PM was calculated from ‘prosthesis internal orifice diameter, as provided by the manufacturer’.

The problem with these studies as with other similar studies is the use of the manufacturer stated orifice size, using different criteria for grading severity of VP-PM and not determining the causes of death. To be able to address correctly the issue of mortality in patients with VP-PM the following data should be obtained:

1. PHVA should be calculated from echocardiographic/Doppler studies obtained at 6 and/or 12 months after PHV implantation [7];
2. Severe VP-PM should be defined as PHVA ≤ 0.6 cm2/m2 (it is not possible to measure PHVA with any degree of precision to a hundredth of a centimeter) [7]; and
3. Determine the cause of death by a ‘blinded’ committee, or in an adjudicative manner, whether the death is due to cardiac cause related to PHV, cardiac not related to PHV or non-cardiac.

References

  1. Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation 1978;58:20-24.[Abstract/Free Full Text]
  2. Howell NJ, Keogh BE, Barnet V, Bonser RS, Graham TR, Rooney SJ, Wilson IC, Pagano D. Patient prosthesis mismatch does not affect survival following aortic valve replacement. Eur J Cardiothorac Surg 2006;30:10-14.[Abstract/Free Full Text]
  3. Walther T, Rastan A, Falk V, Lehmann S, Garbade J, Funkat AK, Mohr FW, Gummert JF. Patient prosthesis mismatch affects short- and-long-term outcome after aortic valve replacement. Eur J Cardiothorac Surg 2006;30:15-19.[Abstract/Free Full Text]
  4. Moon MR, Pasque MK, Munfakh NA, Melby SJ, Lawton JS, Moazami N, Codd JE, Crabtree TD, Barner HB, Damiano Jr. RJ. Prosthesis-patient mismatch after aortic valve replacement: impact of age and body size on late survival. Ann Thorac Surg 2006;81:481-489.[Abstract/Free Full Text]
  5. Mohan S, Kohsaka S, Contreras A, Lee V, Reul RM, Reul G, Coulter SA. Prosthesis-patient mismatch affects long-term survival after mechanical aortic valve replacement. J Am Coll Cardiol 2006;46:282A.
  6. Mohty-Echahidi D, Malouf JF, Girard SE, Schaff HV, Grill DE, Enriquez-Sarano MD, Miller F. Impact of prosthesis-patient mismatch on long-term survival in patients with small St. Jude Medical Mechanical Prostheses in the aortic position. Circulation 2006;113:420-426.[Abstract/Free Full Text]
  7. Rahimtoola SH. Choice of prosthetic heart valve for adult patients. J Am Coll Cardiol 2003;41:893-904.[Abstract/Free Full Text]



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