title: Impact of prosthesis-patient mismatch on the regression of secondary mitral regurgitation after isolated aortic valve replacement with a bioprosthetic valve in patients with severe aortic stenosis.
abstract: BACKGROUND
  Secondary mitral regurgitation (SMR) is generally reduced after isolated aortic valve replacement (AVR), but there is important interindividual variability in the magnitude of this reduction. Prosthesis-patient mismatch (PPM) may hinder normalization of left ventricular geometry and pressure overload following AVR, therefore we aimed to investigate the relationship between PPM and regression of SMR following AVR for aortic valve stenosis.
  
  
  RESULTS
  A total of 419 patients with AS who underwent isolated AVR at 2 institutions and presenting moderate SMR (mitral regurgitant volume 30 to 45 mL/beat) not considered for surgical correction were included in this study. Clinical and echocardiographic follow-up were completed at a median follow-up time of 37 months. PPM was defined as an indexed effective orifice area ≤0.85 cm(2)/m(2) and was found in 170/419 patients (40.6%). There were no significant differences in baseline and operative characteristics between patients with or without PPM. Patients with PPM had less regression of SMR following AVR compared with those with no PPM (change in mitral regurgitant volume: -11±4 versus -17±5 mL, respectively; P<0.0001). Variables significantly associated with postoperative change in mitral regurgitant volume on univariable analysis were entered in a multivariable linear regression model, which showed indexed effective orifice area (P<0.0001) and left atrial diameter (P=0.006) to be independently associated with mitral regurgitant volume improvement. Patients with PPM also had less postoperative improvement in 6-minute walking test distance (80±78 versus 42±41 m, P<0.0001).
  
  
  CONCLUSIONS
  PPM is associated with lesser regression of SMR following AVR. This unfavorable effect was associated with worse functional capacity. These findings emphasize the importance of operative strategies aiming to prevent PPM in patients with aortic valve stenosis and concomitant SMR.
authors.affiliation: Academic Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, UK. emilianoangeloni@gmail.com
authors.forename: Emiliano
authors.initials: E
authors.lastname: Angeloni
authors.forename: Giovanni
authors.initials: G
authors.lastname: Melina
authors.forename: Philippe
authors.initials: P
authors.lastname: Pibarot
authors.forename: Umberto
authors.initials: U
authors.lastname: Benedetto
authors.forename: Simone
authors.initials: S
authors.lastname: Refice
authors.forename: Giuseppino M
authors.initials: GM
authors.lastname: Ciavarella
authors.forename: Antonino
authors.initials: A
authors.lastname: Roscitano
authors.forename: Riccardo
authors.initials: R
authors.lastname: Sinatra
authors.forename: John R
authors.initials: JR
authors.lastname: Pepper
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000150:complications / Q000601:surgery*; D001705:Bioprosthesis; D015150:Echocardiography, Doppler / Q000379:methods; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000000981:diagnostic imaging* / Q000601:surgery*; D011183:Postoperative Complications / Q000000981:diagnostic imaging; D011474:Prosthesis Design; D017755:Prosthesis Fitting; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016896:Treatment Outcome