title: Novel thoughts on patient-prosthesis mismatch in aortic valve replacement: the rationale for the PAR I trial.
abstract: The hemodynamic performance of prosthetic tissue valves is influenced by valve design and valve-specific sizing strategies. Design determines the actual geometric opening area (GOA) of the prosthetic valve and sizing strategy its actual chosen size. Currently, hemodynamic performance is assessed by determining the effective orifice area (EOA; derived from the continuity equation by relating flow velocities with the area of the left ventricular outflow tract [LVOTA]). The question whether a valve is too small (patient-prosthesis mismatch [PPM]) is currently addressed by relating EOA to body surface area (EOA index [EOAi]). However, this relation may not be appropriate because the EOAi relates flow velocity to patient-specific anatomic parameters twice (i.e., LVOTA and body surface area). This potential confounder may explain the controversies regarding PPM. However, intuitively, leaving a gradient behind after aortic valve replacement cannot be irrelevant. PPM becomes even more relevant with transcatheter valve-in-valve implantation, where a second prosthesis is taking up inner space of a valve that may have already been too small initially. Thus, a reliable method to determine the presence of PPM is needed. The Prosthesis-to-Annulus Relation I (PAR I) trial is a German multicenter study assessing the relation between the prosthetic GOA and the LVOTA as a potentially new parameter for the prediction of hemodynamic outcome. The results may possibly guide future valve size selection and may allow prediction of functionally relevant PPM. Here, we will demonstrate the shortcomings of the currently applied EOAi for the assessment of hemodynamic relevance and present the rationale for the PARI trial, which recently started recruiting patients.
authors.affiliation: Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
authors.forename: Torsten
authors.initials: T
authors.lastname: Doenst
authors.affiliation: Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
authors.forename: Paulo A
authors.initials: PA
authors.lastname: Amorim
authors.affiliation: Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
authors.forename: Mahmoud
authors.initials: M
authors.lastname: Diab
authors.affiliation: Department of Cardiology and Angiology, University of Leipzig, Leipzig, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Hagendorff
authors.affiliation: Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany.
authors.forename: Gloria
authors.initials: G
authors.lastname: Faerber
authors.affiliation: Department of Vardiac Surgery, Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg, Germany.
authors.forename: Jürgen
authors.initials: J
authors.lastname: Graff
authors.affiliation: Department of Vardiac Surgery, Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg, Germany.
authors.forename: Ardawan
authors.initials: A
authors.lastname: Rastan
authors.affiliation: Department of Cardiac Surgery, Hospital Bogenhausen, Munich, Germany.
authors.forename: Oliver
authors.initials: O
authors.lastname: Deutsch
authors.affiliation: Department of Cardiac Surgery, Hospital Bogenhausen, Munich, Germany.
authors.forename: Walter
authors.initials: W
authors.lastname: Eichinger
mesh_terms: D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001830:Body Surface Area; D002985:Clinical Protocols; D005858:Germany; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation*; D006439:Hemodynamics; D006801:Humans; D018579:Patient Selection; D011474:Prosthesis Design; D012039:Regional Blood Flow; D012107:Research Design; D012307:Risk Factors; D016896:Treatment Outcome