title: Severe prosthesis-patient mismatch after aortic valve replacement for aortic stenosis: Analysis of risk factors for early and long-term mortality.
abstract: Severe prosthesis-patient mismatch (PPM) is considered to further decrease survival compared to moderate PPM. This study aimed to assess the impact of severe PPM on survival after aortic valve replacement (AVR).
  
  
  
  We retrospectively studied 2404 consecutive patients with PPM who underwent first-time AVR for pure stenosis between January 2003 and December 2014. Mismatch was moderate for indexed effective valve orifice >0.65 to <0.85cm2/m2and severe for indexed effective valve orifice ≤0.65cm2/m2. Moderate mismatch occurred in 2165 patients (89%), and severe in 239 (11%) patients. Logistic multiple regression with bootstrapping and propensity score analyses were performed using 29 clinical and demographic data to assess the risk-adjusted impact of severe mismatch on mortality. The Cox proportional hazards model was constructed to process the long-term outcome.
  
  
  
  Early mortality was 2.3% (51/2165) in moderate mismatch group and 3.7% (9/239) in severe mismatch group (p=0.2). Mortality at 5 and 10 years, was 218/1470 (14.8%) and 252/585 (43.1%) for moderate mismatch and 43/198 (21.7%) and 61/105 (58.1%) for severe mismatch (p=0.02 and p=0.006). Multivariable predictors of late mortality were as follows: age ≥70 years, left ventricular ejection fraction ≤40%, indexed left ventricular mass >220g/m2and concomitant coronary artery revascularization. After propensity score matching, conditional logistic regression analysis demonstrated no relationship between severe mismatch and increased mortality at 5 postoperative years (HR, 0.9; 95% CI, 0.7-1.6; p=0.06), whereas it was significant at 10 postoperative years (HR, 1.9; 95% CI, 1.2-2.5; p=0.03). During the follow-up, severe mismatch was associated with more frequent hospital readmissions for cardiac events (0.12 vs. 0.08 events/patient/year, p=0.007).
  
  
  
  Patients with severe mismatch had lower long-term survival and higher incidence of hospital readmissions for cardiac events. However, the effect of severe mismatch on outcome appeared mainly related to the preoperative risk profile of each patient.
authors: Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy. Electronic address: vitomannacio2@libero.it.
authors: Vito
authors: V
authors: Mannacio
authors: Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
authors: Luigi
authors: L
authors: Mannacio
authors: Cardiac Surgery Unit, Casa di Cura Montevergine, Mercogliano, Italy.
authors: Emilo
authors: E
authors: Mango
authors: Department of Cardiology, Azienda Ospedaliera Santobono-Pausillipon, Naples, Italy.
authors: Anita
authors: A
authors: Antignano
authors: Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
authors: Michele
authors: M
authors: Mottola
authors: Cardiac Surgery Unit, Casa di Cura Montevergine, Mercogliano, Italy.
authors: Sergio
authors: S
authors: Caparrotti
authors: Department of Cardiac Surgery, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy.
authors: Francesco
authors: F
authors: Musumeci
authors: Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.
authors: Carlo
authors: C
authors: Vosa
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006350:Heart Valve Prosthesis / Q000009:adverse effects*; D019918:Heart Valve Prosthesis Implantation / Q000401:mortality*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality* / Q000503:physiopathology; D011184:Postoperative Period; D057216:Propensity Score; D016016:Proportional Hazards Models; D017755:Prosthesis Fitting; D012189:Retrospective Studies; D012307:Risk Factors; D013318:Stroke Volume; D016896:Treatment Outcome; D016277:Ventricular Function, Left
keywords: Aortic stenosis; Aortic valve replacement; Moderate prosthesis-patient mismatch; Severe prosthesis-patient mismatch