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Impact of Patient-Prosthesis Mismatch on Octogenarians after Aortic Valve Replacement

Elsayed M. Elmistekawy, Harry Lapierre, Diem T. Tran, Marc Ruel, Thierry G. Mesana, Buu-Khanh Lam.
Ottawa Heart Institute, Ottawa, ON, Canada.


OBJECTIVE:
Patient-prosthesis mismatch (PPM) following aortic valve replacement (AVR) in the octogenarian population has not been well described. The objective of this study was to determine the impact of PPM on early and late outcomes in this very elderly population.
METHODS:
Between 1999 and 2009, 385 octogenarians underwent AVR (171, 44%) or AVR/CABG (214, 56%) at our institution. Mean age was 83 +/- 2 yrs; 204 (53%) were male and all received either a pericardial (175, 45%) or porcine (210, 55%) bioprosthesis for predominantly aortic stenosis (376, 98%). PPM was defined as a valve indexed effective orifice area (IEOA) <0.85cm2/m2. Mean follow-up was 4.6 yrs (median 3.9, 1644 patient-yrs) and completed. Parametric and non-parametric analyses were used to determine predictors of outcomes.
RESULTS:
Patient-prosthesis mismatch was identified in 203 (53%) patients. Hospital mortality was 8%; predictors of early mortality included preoperative NYHA class (OR19, 4-86), low cardiac output state (OR6.6, 2-19), postoperative CVA (OR11.6, 2-59) and diabetes (OR9.5, 1.4-64). PPM was not a predictor of early mortality. Late mortality was predicted by PPM with IEOA <0.75cm2/m2 (HR1.8, 1.1-2.9), coronary artery disease (HR2.2, 1.4-3.5), COPD (HR6.3, 2.5-16) and prolonged ICU stay (HR1.03, 1.01-1.06). Overall survival at 1, 2, and 10 yrs was respectively 95%, 80% and 60%. One, 5 and 10-yr survival for patients with IEOA <0.75cm2/m2 was 92%, 73% and 50% (P=.04). Echocardiographic trans-prosthetic valve gradients were predicted by PPM (P<.0001).
CONCLUSIONS:
Patient-prosthesis mismatch occurred in over half of octogenarians undergoing AVR +/- CABG. PPM did not affect early mortality but had a negative impact on late survival when moderate in grade (<0.75 cm2/m2). In this higher risk population with prolonged life expectancy after surgery, a too pragmatic approach to AVR may be detrimental to the patients in the long run. Aortic root enlargement should be considered in selected patients.
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