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Review
. 2021 Jun 4:8:670457.
doi: 10.3389/fcvm.2021.670457. eCollection 2021.

Clinical and Technical Challenges of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Implantation

Pier Pasquale Leone  1   2 , Fabio Fazzari  2 , Francesco Cannata  1   2 , Jorge Sanz-Sanchez  1   2 , Antonio Mangieri  2 , Lorenzo Monti  2 , Ottavia Cozzi  1   2 , Giulio Giuseppe Stefanini  1   2 , Renato Bragato  2 , Antonio Colombo  2 , Bernhard Reimers  2 , Damiano Regazzoli  2
Affiliations
Review

Clinical and Technical Challenges of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Implantation

Pier Pasquale Leone et al. Front Cardiovasc Med. .

Abstract

Prosthesis-patient mismatch (PPM) is present when the effective area of a prosthetic valve inserted into a patient is inferior to that of a normal human valve; the hemodynamic consequence of a valve too small compared with the size of the patient's body is the generation of higher than expected transprosthetic gradients. Despite evidence of increased risk of short- and long-term mortality and of structural valve degeneration in patients with PPM after surgical aortic valve replacement, its clinical impact in patients subject to transcatheter aortic valve implantation (TAVI) is yet unclear. We aim to review and update on the definition and incidence of PPM after TAVI, and its prognostic implications in the overall population and in higher-risk subgroups, such as small aortic annuli or valve-in-valve procedures. Last, we will focus on the armamentarium available in order to reduce risk of PPM when planning a TAVI procedure.

Keywords: TAVI; aortic stenosis; prosthesis-patient mismatch; small annuli; valve-in-valve.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Proposed flowchart for differential diagnosis between high-flow states, transcatheter heart valve (THV) stenosis, and prosthesis-patient mismatch (PPM). 3D, three-dimensional; AT, acceleration time; CMR, cardiac magnetic resonance; CT, computed tomography; Δ, variation; ΔP, pressure gradient; DVI, Doppler velocity index; EOA, effective orifice area; EOAi, indexed effective orifice area; EOAip, predicted indexed effective orifice area; ELCo, energy loss coefficient; ET, ejection time; LVOT, left ventricular outflow tract; PPM, prosthesis-patient mismatch; PVL, paravalvular leak; TEE, transesophageal echocardiography; THV, transcatheter heart valve; TTE, transthoracic echocardiography; V, velocity.
Figure 2
Figure 2
Multimodality imaging for differential diagnosis of high trans-prosthetic gradients in patients with THV. Case 1. TEE showing an isoechoic mobile mass (*) adherent to THV (arrows) cusps, causing valve obstruction; blood cultures confirmed infective endocarditis (A,B). Case 2. TEE revealing severe paravalvular (arrows) leak (C, arrowheads); the regurgitant jet is also shown during CMR cine sequences (D, arrowheads), and can be quantified using phase contrast sequences. Case 3. TEE in a patient known for valve-in-valve procedure showing an isoechoic mass (E, white star) in left coronary sinus, affecting cusp motion (arrowhead). CT (F), confirmed the mass (white star) arising between the two valves, and whose features and density were consistent with thrombus.
Figure 3
Figure 3
Aortic annulus sizing with CT and 3D TEE. Transverse CT plane aligned at the lowest insertion points of aortic leaflets (A) and orthogonal planes oriented along the main axis of LVOT in short (B) and long axis (C) views. TEE long-axis mid-esophageal view (D), view of the aortic annulus perpendicular to the mid-esophageal view (E), aortic annulus sizing (F), and 3D visualization and measurement of aortic annulus (G).
Figure 4
Figure 4
Proposed algorithm for prevention of PPM according to chosen approach of aortic valve replacement. BAV, bicuspid aortic valve; EOAip, predicted indexed effective orifice area; LVOT, left ventricular outflow tract; TF, transfemoral; THV, transcatheter heart valve.
See this image and copyright information in PMC

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