Impact of patient-prosthesis mismatch after transcatheter aortic valve-in-valve implantation in degenerated bioprostheses

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• 作者：Moritz Seiffert ; MD^a ; ^{m.seiffert@uke.de} ; Lenard Conradi ; MD^a ; Stephan Baldus ; MD^b ; Malgorzata Knap ; MD^b ; Johannes Schirmer ; MD^a ; Olaf Franzen ; MD^b ; Dietmar Koschyk ; MD^b ; Thomas Meinertz ; MD^b ; Hermann Reichenspurner ; MD ; PhD^a ; Hendrik Treede ; MD^a
• 关键词：28.1 ; 35.2 ; 35.3.3 ; 35.3.5
• 刊名：The Journal of Thoracic and Cardiovascular Surgery
• 出版年：2012
• 出版时间：March, 2012
• 年：2012
• 卷：143
• 期：3
• 页码：617-624
• 全文大小：686 K

文摘

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Objective

Transcatheter valve-in-valve implantation is evolving as an alternative to reoperative valve replacement in high-risk patients with degenerated bioprostheses. Nevertheless, hemodynamic performance is limited by the previously implanted xenograft. We report our experience with patient-prosthesis mismatch (PPM) after valve-in-valve implantation in the aortic position.

Methods

Eleven patients (aged 79.3 ¡À 6.1 years) received transapical implantation of a balloon-expandable pericardial heart valve into a degenerated bioprosthesis (size, 23.9 ¡À 1.6 mm; range, 21-27 mm) in the aortic position. All patients were considered high risk for surgical valve replacement (logistic European System for Cardiac Operative Risk Evaluation, 31.8 % ¡À 24.1 % ). Severe PPM was defined as an indexed effective orifice area less than 0.65 cm²/m², determined by discharge echocardiography.

Results

Severe PPM was evident in 5 patients (group 1) and absent in 6 patients (group 2). Mean transvalvular gradients decreased from 29.2 ¡À 15.4 mm Hg before implantation to 21.2 ¡À 9.7 mm Hg at discharge (group 1) and from 28.2 ¡À 9.0 mm Hg before implantation to 15.2 ¡À 6.5 mm Hg at discharge (group 2). Indexed effective orifice area increased from 0.5 ¡À 0.1 cm²/m² to 0.6 ¡À 0.1 cm²/m² and from 0.6 ¡À 0.3 cm²/m² to 0.8 ¡À 0.3 cm²/m². Aortic regurgitation decreased from grade 2.0 ¡À 1.1 to 0.4 ¡À 0.5 overall. No differences in New York Heart Association class improvement or survival during follow-up were observed. One patient required reoperation for symptomatic PPM 426 days after implantation.

Conclusions

Valve-in-valve implantation can be performed in high-risk surgical patients to avoid reoperation. However, PPM frequently occurs, making adequate patient selection crucial. Small bioprostheses (<23 mm) should be avoided. Implantation into 23-mm xenografts can be recommended only for patients with a body surface area less than 1.8 m². Larger prostheses seem to carry a lower risk for PPM. Although no delay in clinical improvement was seen at short-term, 1 PPM-related surgical intervention raises concern regarding long-term performance.