Prevalence And Impact Of Prosthesis-Patient Mismatch In Patients With Paradoxical Low-Flow Severe Aortic Stenosis

Purpose: Patients with severe aortic stenosis (AS) and paradoxical low flow (PLF) (indexed stroke volume< 35ml/m2) despite preserved left ventricular ejection fraction >50%, have worse outcome compared to those with AS but normal flow. Moreover, Prosthesis-Patient Mismatch (PPM) (indexed prosthetic valve effective orifice area< 0.85cm2/m2) after aortic valve replacement (AVR) is a predictor of higher mortality. However, the impact of PPM in patients with PLFAS on long-term survival is unknown. Our aim was to analyze the prevalence and the impact on long-term survival of PPM in patients with PLFAS. Methods: 667 consecutive patients (age 74±8 years, 42% female, AVA 0.69±0.16 cm2) with preserved LVEF who underwent AVR for severe AS at our institution between 2000 and 2010 were included in this study. Patients were divided into 4 groups according to the presence/absence of PLF at cardiac catheterization and presence/absence of PPM following AVR and we compared short and long-term survival between these groups. Results: Among the 667 patients, 26% had PLFAS and PPM occurred in 54% of patients after AVR. Compared to patients with no PLF & no PPM (36% of the total cohort), those with PLF & PPM (15%) were significantly older, with more comorbidities. The 30-day mortality did not differ between the PLF- PPM and no-PLF-no PPM group. The 10-yr survival rate was significantly reduced in the PLF-PPM (37±9%) group compared to no PLF-no PPM (70±5%; p=0.003). In multivariate analysis adjusting for all predictors of survival, concomitant presence of PLF & PPM was an independent predictor of survival (HR= 2.68 95% CI: 1.5-4.4; p=0.0003) 10-year survival according to PPM/PLF 10-year survival according to PPM/PLF Conclusion: In this catheterization-based study, patients with PLF and PPM have worse outcome when compared to those without these 2 conditions.