Patient–prosthesis mismatch after mitral valve replacement: complex enigma with more than one solution

Patient–prosthesis mismatch after mitral valve replacement: complex enigma with more than one... European Journal of Cardio-Thoracic Surgery 0 (2018) 1 LETTER TO THE EDITOR postoperative TPG of the cumulative population receiving the single-size ON- Patient–prosthesis mismatch after mitral X prosthesis was similar to the population receiving a different prosthesis (with a patient-specific calibrated size). Furthermore, in the latest study, an in- valve replacement: complex enigma with crease in the size of prosthesis did not correlate with a reduced TPG. On the basis of such results, we do not support the concept that ‘unlike other risk fac- more than one solution tor for PAH, mitral PPM may be prevented through a prospective strategy during surgery’ as stated in the study by Ammannaya et al. The size of pros- Pasquale Totaro* and Stefano Pelenghi thesis is not the only determinant of postoperative performances as physio- Division of Cardiac Surgery, IRCCS Foundation Hospital San Matteo, Pavia, logical factors could be more relevant in causing a high postoperative TPG. Italy Furthermore, the increased surgical risk of inserting a bigger prosthesis, to avoid ‘potential’ mitral PPM, is not supported by the current limited evidence Received 21 February 2018; accepted 26 March 2018 of a real correlation between a smaller-sized prosthesis and clinical outcomes. Keywords: Mitral valve replacement � Patients prosthesis mismatch � Transprosthesis gradient REFERENCES We read with interest the article by Ammannaya et al. [1] addressing the com- plex enigma of mitral patient–prosthesis mismatch (PPM), which we addressed [1] Ammannaya GKK, Mishra P, Khandekar JV, Mohapatra CHR, Seth HS, in 2007 [2, 3], and we would like to add few comments. We previously showed Raut C. Effect of prosthesis patient mismatch in mitral position on pul- a key factor when dealing with mitral PPM: the estimated in vitro effective ori- monary hypertension. Eur J Cardiothorac Surg 2017;52:1168–74. fice area (EOA)/effective orifice area index (EOAI) of a mitral prosthesis does [2] Totaro P, Argano V. Patient-prosthesis mismatch after mitral valve re- not accurately predict in vivo postoperative EOA/EOAI. In small-sized biopros- placement: myth or reality? J Thorac Cardiovasc Surg 2007;134:697–701. thesis, in vivo EOA/EOAI resulted, indeed, in a significantly higher value than [3] Totaro P, Argano V. Reply to Pibarot et al: patients-prosthesis mismatch those reported as reference values for the same prosthesis. Incidence of PPM after mitral valve replacement back to reality. J Thoracic Cardiovasc Surg in our study, therefore, was much lower than the estimated. The 2nd finding 2008;135:465–6. of our study was the lack of correlation between increased prosthesis size and [4] Li M, Dumesnil JG, Mathieu P, Pibarot P. Impact of valve prosthesis- increased EOA/EOAI. As the authors clearly state, mitral PPM was associated patients mismatch on pulmonary arterial pressure after mitral valve re- with an increased rate of persistent postoperative pulmonary hypertension [4, placement. J Am Coll Cardiol 2005;45:1034–10. 5]. Ammannaya et al. stated, however, that the reported incidence of PPM [5] Magne J, Mathieu P, Dumesnil JG, Tanne D, Dagenais F, Doyle D et al. varies significantly (from 7% to 71%) according to different methods of evalu- Impact of prosthesis-patients mismatch on survival after mitral valve re- ation [6]. For this reason, despite the fact that the persistence of pulmonary placement. Circulation 2007;115:1417–25. hypertension after MVR is surely a relevant clinical aspect, we do believe that [6] Cho I-J, Hong G-R, Lee SH, Chang SB-C, Shim CY, Chang H-J et al. its correlation with a smaller-sized mitral prosthesis cannot be fully supported. Prosthesis-patient mismatch after mitral valve replacement: comparison As a consequence of our previous study, we have adopted the ON-X ‘one size of different methods of effective orifice area calculation. Yonsei Med J fits all’ prosthesis in our practice, and we are reviewing the results. In our pre- 2016;57:328–36. liminary data on 146 patients, who underwent MVR over a 4-year period, to overcome the debate regarding the method of definition of PPM, we focused on the measurement of postoperative in vivo peak/mean transprosthesis gra- *Corresponding author. Division of Cardiac Surgery, IRCCS Foundation dient (TPG) rather than EOA/EOAI. Increased TPG is indeed considered as an Hospital San Matteo, Piazzale Golgi, 27100 Pavia, Italy. Tel: +39-3283678762; essential aspect of PPM definition, as it is the main mechanism causing the fax: +39-2-8053331; e-mail: pasqtotaro@libero.it (P. Totaro). persistence of high pulmonary pressure. Overall incidence of significantly increased TPG of our group was <10%. No correlation was found between the doi:10.1093/ejcts/ezy163 incidence of high TPG and type (or size) of prosthesis. More specifically, The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Downloaded from https://academic.oup.com/ejcts/advance-article-abstract/doi/10.1093/ejcts/ezy163/4978191 by Ed 'DeepDyve' Gillespie user on 07 June 2018 LETTER TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

Patient–prosthesis mismatch after mitral valve replacement: complex enigma with more than one solution

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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Abstract

European Journal of Cardio-Thoracic Surgery 0 (2018) 1 LETTER TO THE EDITOR postoperative TPG of the cumulative population receiving the single-size ON- Patient–prosthesis mismatch after mitral X prosthesis was similar to the population receiving a different prosthesis (with a patient-specific calibrated size). Furthermore, in the latest study, an in- valve replacement: complex enigma with crease in the size of prosthesis did not correlate with a reduced TPG. On the basis of such results, we do not support the concept that ‘unlike other risk fac- more than one solution tor for PAH, mitral PPM may be prevented through a prospective strategy during surgery’ as stated in the study by Ammannaya et al. The size of pros- Pasquale Totaro* and Stefano Pelenghi thesis is not the only determinant of postoperative performances as physio- Division of Cardiac Surgery, IRCCS Foundation Hospital San Matteo, Pavia, logical factors could be more relevant in causing a high postoperative TPG. Italy Furthermore, the increased surgical risk of inserting a bigger prosthesis, to avoid ‘potential’ mitral PPM, is not supported by the current limited evidence Received 21 February 2018; accepted 26 March 2018 of a real correlation between a smaller-sized prosthesis and clinical outcomes. Keywords: Mitral valve replacement � Patients prosthesis mismatch � Transprosthesis gradient REFERENCES We read with interest the article by Ammannaya et al. [1] addressing the com- plex enigma of mitral patient–prosthesis mismatch (PPM), which we addressed [1] Ammannaya GKK, Mishra P, Khandekar JV, Mohapatra CHR, Seth HS, in 2007 [2, 3], and we would like to add few comments. We previously showed Raut C. Effect of prosthesis patient mismatch in mitral position on pul- a key factor when dealing with mitral PPM: the estimated in vitro effective ori- monary hypertension. Eur J Cardiothorac Surg 2017;52:1168–74. fice area (EOA)/effective orifice area index (EOAI) of a mitral prosthesis does [2] Totaro P, Argano V. Patient-prosthesis mismatch after mitral valve re- not accurately predict in vivo postoperative EOA/EOAI. In small-sized biopros- placement: myth or reality? J Thorac Cardiovasc Surg 2007;134:697–701. thesis, in vivo EOA/EOAI resulted, indeed, in a significantly higher value than [3] Totaro P, Argano V. Reply to Pibarot et al: patients-prosthesis mismatch those reported as reference values for the same prosthesis. Incidence of PPM after mitral valve replacement back to reality. J Thoracic Cardiovasc Surg in our study, therefore, was much lower than the estimated. The 2nd finding 2008;135:465–6. of our study was the lack of correlation between increased prosthesis size and [4] Li M, Dumesnil JG, Mathieu P, Pibarot P. Impact of valve prosthesis- increased EOA/EOAI. As the authors clearly state, mitral PPM was associated patients mismatch on pulmonary arterial pressure after mitral valve re- with an increased rate of persistent postoperative pulmonary hypertension [4, placement. J Am Coll Cardiol 2005;45:1034–10. 5]. Ammannaya et al. stated, however, that the reported incidence of PPM [5] Magne J, Mathieu P, Dumesnil JG, Tanne D, Dagenais F, Doyle D et al. varies significantly (from 7% to 71%) according to different methods of evalu- Impact of prosthesis-patients mismatch on survival after mitral valve re- ation [6]. For this reason, despite the fact that the persistence of pulmonary placement. Circulation 2007;115:1417–25. hypertension after MVR is surely a relevant clinical aspect, we do believe that [6] Cho I-J, Hong G-R, Lee SH, Chang SB-C, Shim CY, Chang H-J et al. its correlation with a smaller-sized mitral prosthesis cannot be fully supported. Prosthesis-patient mismatch after mitral valve replacement: comparison As a consequence of our previous study, we have adopted the ON-X ‘one size of different methods of effective orifice area calculation. Yonsei Med J fits all’ prosthesis in our practice, and we are reviewing the results. In our pre- 2016;57:328–36. liminary data on 146 patients, who underwent MVR over a 4-year period, to overcome the debate regarding the method of definition of PPM, we focused on the measurement of postoperative in vivo peak/mean transprosthesis gra- *Corresponding author. Division of Cardiac Surgery, IRCCS Foundation dient (TPG) rather than EOA/EOAI. Increased TPG is indeed considered as an Hospital San Matteo, Piazzale Golgi, 27100 Pavia, Italy. Tel: +39-3283678762; essential aspect of PPM definition, as it is the main mechanism causing the fax: +39-2-8053331; e-mail: pasqtotaro@libero.it (P. Totaro). persistence of high pulmonary pressure. Overall incidence of significantly increased TPG of our group was <10%. No correlation was found between the doi:10.1093/ejcts/ezy163 incidence of high TPG and type (or size) of prosthesis. More specifically, The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Downloaded from https://academic.oup.com/ejcts/advance-article-abstract/doi/10.1093/ejcts/ezy163/4978191 by Ed 'DeepDyve' Gillespie user on 07 June 2018 LETTER TO THE EDITOR

Journal

European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: Apr 19, 2018

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