title: Patient-prosthesis mismatch in aortic valve replacement: really tolerable?
abstract: OBJECTIVE
  Several studies have demonstrated favorable results despite patient-prosthesis mismatch after aortic valve replacement with the use of third generation prostheses. Our aim was to determine whether this mismatch is always tolerable.
  
  
  METHODS
  A clinical-echocardiographic study has been performed in 339 consecutive patients who underwent aortic valve replacement because of aortic stenosis. In-hospital outcome and left ventricular mass index regression (1st month-1st year) were analyzed in the presence or absence of mismatch (indexed effective orifice area < or =0.85cm(2)/m(2)). The influence of high degrees of preoperative left ventricular mass on in-hospital mortality has also been evaluated. Left ventricular mass index was considered increased if the calculated value was over the superior quartile of the frequency distribution of all the values observed in both sexes.
  
  
  RESULTS
  Mismatch was found in 38% of the patients. In the absence of mismatch, the absolute mass regression was proportional to the preoperative left ventricular mass. This regression was higher in patients with increased left ventricular mass indexed (vs not increased): -38.0+/-7.8 vs -8.8+/-4.7g/m(2), p<0.01 (1st month) and -67.7+/-16.9vs -23.5+/-6.7g/m(2), p<0.05 (1st year). Mass regression was impaired in the presence of mismatch, particularly, in patients with previously increased left ventricular mass: -8.2+/-11.6 vs -5.6+/-6.3g/m(2) (p=0.83) and -24.6+/-12.6 vs -11.7+/-10.5g/m(2) (p=0.54). This worse regression was reflected on a 100% incidence of residual hypertrophy at follow-up (1st month-1st year). In the presence of mismatch, increased ventricular mass was associated with higher mortality: 14.7% vs 2.1% (p<0.01). In the absence of mismatch, ventricular mass was not associated with mortality: 4.1 vs 2.5% (p=0.55).
  
  
  CONCLUSIONS
  In patients with severe ventricular hypertrophy it may be important to elude patient-prosthesis mismatch to avoid a significant increase in mortality and improve ventricular mass regression. Mismatch may be tolerable in those patients with lesser degree of hypertrophy.
authors.affiliation: Universitary General Hospital of Valencia, Av. Tres Cruces s/n, C/ Artes Gráficas no. 4, esc. izq. pta. 3, 46014 Valencia, Spain. rgfuster@terra.com
authors.forename: Rafael García
authors.initials: RG
authors.lastname: Fuster
authors.forename: José A
authors.initials: JA
authors.lastname: Montero Argudo
authors.forename: Oscar Gil
authors.initials: OG
authors.lastname: Albarova
authors.forename: Fernando Hornero
authors.initials: FH
authors.lastname: Sos
authors.forename: Sergio Cánovas
authors.initials: SC
authors.lastname: López
authors.forename: María Bueno
authors.initials: MB
authors.lastname: Codoñer
authors.forename: José A
authors.initials: JA
authors.lastname: Buendía Miñano
authors.forename: Ignacio Rodríguez
authors.initials: IR
authors.lastname: Albarran
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D015150:Echocardiography, Doppler; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D017052:Hospital Mortality; D006801:Humans; D017379:Hypertrophy, Left Ventricular / Q000000981:diagnostic imaging / Q000473:pathology; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011379:Prognosis; D011446:Prospective Studies; D011474:Prosthesis Design; D012016:Reference Values; D012307:Risk Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left