Reply: Prosthesis−patient mismatch: No consensus yet

The author reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The author reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The definition and clinical impact of prosthesis−patient mismatch (PPM) has been a matter of intense debate and controversy.1Rahimtoola S.H. The problem of valve prosthesis−patient mismatch.Circulation. 1978; 58: 20-24Crossref PubMed Scopus (653) Google Scholar,2Pibarot P. Dumesnil J.G. Hemodynamic and clinical impact of prosthesis−patient mismatch in the aortic valve position and its prevention.J Am Coll Cardiol. 2000; 36: 1131-1141Crossref PubMed Scopus (475) Google Scholar In response to the manuscript “Why the Categorization of Indexed Effective Orifice Area Is Not Justified for the Classification of Prosthesis−Patient Mismatch,” Ternacle and Pibarot3Ternacle J. Pibarot P. Prosthesis−patient mismatch is not synonymous with elevated transvalvular pressure gradient.J Thorac Cardiovasc Surg Open. 2021; 8: 242-243Google Scholar proposed a new algorithm to better categorize patients having true severe PPM. They have used solid arguments to demonstrate that although mean transprosthetic gradients (mΔp) may underestimate the presence of true severe PPM, the opposite occurs when using measured effective orifice area indexes (mEOAi) for the same purpose. Considering that echocardiographic measurements were correctly performed and in the absence of low-flow states, the authors suggest that in patients with mΔp <20 mm Hg, predicted EOAi is more reliable than mEOAi to confirm the presence or absence of true PPM.3Ternacle J. Pibarot P. Prosthesis−patient mismatch is not synonymous with elevated transvalvular pressure gradient.J Thorac Cardiovasc Surg Open. 2021; 8: 242-243Google Scholar The challenge to establish accurate and reliable “normal” EOA reference value tables for different prosthetic valves is reflected by the creation of a task force in this respect. Reference EOAs provided by valve manufacturers are based in “in vitro” pulse duplicator studies and, for reasons beyond the scope of this comment, yield consistently greater values than those observed in clinical practice.4Marquez S. Hon R.T. Yoganathan A.P. Comparative hydrodynamic evaluation of bioprosthetic heart valves.J Heart Valve Dis. 2001; 10: 802-811PubMed Google Scholar Contrary to a geometric orifice area that can be physically measured, EOAs are influenced by imprecisions during echocardiographic data acquisition, circulatory conditions, and individual anatomical characteristics of the left ventricular outflow tract and aortic root.5Zoghbi W.A. Chambers J.B. Dumesnil J.G. Foster E. Gottdiener J.S. Grayburn P.A. et al.Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the task force on prosthetic valves, developed in conjunction with the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography and the Canadian Society of Echocardiography, endorsed by the American College of Cardiology Foundation, American Heart Association, European Association of Echocardiography, a registered branch of the European Society of Cardiology, the Japanese Society of Echocardiography, and Canadian Society of Echocardiography.J Am Soc Echocardiogr. 2009; 22 (quiz 82-4): 975-1014Abstract Full Text Full Text PDF PubMed Scopus (861) Google Scholar,6Kim H.J. Park S.J. Koo H.J. Kang J.W. Yang D.H. Jung S.H. et al.Determinants of effective orifice area in aortic valve replacement: anatomic and clinical factors.J Thorac Dis. 2020; 12: 1942-1951Crossref PubMed Scopus (3) Google Scholar In addition, surgical factors including the choice of the suture technique, use of mattress pledget versus single interrupted sutures, implantation in supra versus intra-annular position, and correct sizing of the stented valve been shown to significantly influence the final mEOAi.7Capelli C. Corsini C. Biscarini D. Ruffini F. Migliavacca F. Kocher A. et al.Pledget-armed sutures affect the haemodynamic performance of biologic aortic valve substitutes: a preliminary experimental and computational study.Cardiovasc Eng Technol. 2017; 8: 17-29Crossref PubMed Scopus (19) Google Scholar,8Cleveland J.D. Bowdish M.E. Eberhardt C.E. Mack W.J. Crabtree J.A. Vassiliades T.A. et al.Evaluation of hemodynamic performance of aortic valve bioprostheses in a model of oversizing.Ann Thorac Surg. 2017; 103: 1866-1876Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar Due to uncertainties to determine the real degree of prosthetic aortic valve obstruction other alternative echocardiographic parameters such as Doppler velocity index, acceleration time, jet contour, valve resistance, percentage stroke work loss, and energy loss have been proposed and may provide additional information in doubtful cases.9Parnell A. Swanevelder J. High transvalvular pressure gradients on intraoperative transesophageal echocardiography after aortic valve replacement: what does it mean?.HSR Proc Intensive Care Cardiovasc Anesth. 2009; 1: 7-18PubMed Google Scholar Others advocate using cardiac magnetic resonance or invasive catheter measurements in discordant cases.10Woldendorp K. Bannon P.G. Grieve S.M. Evaluation of aortic stenosis using cardiovascular magnetic resonance: a systematic review & meta-analysis.J Cardiovasc Magn Reson. 2020; 22: 45Crossref PubMed Scopus (5) Google Scholar In the current era, where different interventional procedures (surgical aortic valve replacement vs transcatheter aortic valve replacement) are being equally offered to a broader range of patients with lower risk profile, younger age, small aortic annulus, bicuspid valves, and reinterventional procedures, it is desirable that a standardized definition of true moderate and severe PPM be uniformly applied and reported in academic research not only to better understand the clinical consequences of the varying degrees of PPM, but also aid in proper patient selection and prosthesis choice based in solid scientific background to improve clinical outcomes. Continued work on the field may help to further clarify the appropriateness and limitations of mEOAi or predicted EOAi in clinical practice. Prosthesis-patient mismatch is not synonymous with elevated transvalvular pressure gradientJTCVS OpenVol. 8PreviewVriesendorp and colleagues1 recently evaluated the relationship between the effective orifice area indexed (EOAi) to body surface area and the postoperative transprosthetic mean gradient in patients undergoing surgical aortic valve replacement (AVR) using a stented bioprosthesis. The authors conclude that the current EOAi thresholds proposed in the American and European society guidelines and the Valve Academic Research Consortium-2 are not appropriate to define prosthesis–patient mismatch (PPM) because their ability to predict high residual transprosthetic gradients is weak. Full-Text PDF Open Access

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