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7, 2005
© 2005 by the American College of Cardiology Foundation ISSN 0735-1097/05/$30.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2004.10.073
Pulmonary arterial (PA) hypertension is a frequent and hypertension after operation varies extensively from one
serious complication of mitral valve diseases, and it is a patient to the other and is often incomplete (5,6).
major risk factor for poor outcome after surgery for mitral The effective orifice area (EOA) of prosthetic valves used
stenosis (1) or mitral regurgitation (2– 4). Not surprisingly, for MVR is often too small in relation to body size, thus
the impact of PA hypertension on morbidity and mortality causing a mismatch between valve EOA and transvalvular
flow (7–10). As a consequence, normally functioning mitral
See page 1041 prostheses often have relatively high gradients that are
similar to those found in patients with mild/moderate mitral
is highly dependent on its degree of severity. Severe PA stenosis (6,9 –11). Residual pressure gradients across mitral
hypertension is associated with a high risk of perioperative prostheses may hinder or delay the regression of left atrial
mortality (10% to 15%) in patients undergoing mitral valve and PA hypertension (7–9). We, therefore, hypothesized
replacement (MVR) as well as with increased mortality in that valve prosthesis-patient mismatch (PPM) might be an
the long term (1–3). Nonetheless, mild PA hypertension is important determinant of the persistence of PA hyperten-
not necessarily benign because it is associated with signifi- sion after MVR. The main objective of this study was, thus,
cantly worse exercise capacity and higher morbidity and to determine the impact of PPM on PA pressure after
mortality. Therefore, the normalization of PA pressure is a MVR.
crucial goal of MVR. Unfortunately, the regression of PA
METHODS
From the Research Group in Valvular Heart Diseases, Research Center of Laval
Hospital/Quebec Heart Institute, Laval University, Sainte-Foy, Quebec, Canada. Patient population. We retrospectively analyzed the data
This work was supported by the Canadian Institutes of Health Research (MOP of patients with a mitral prosthesis who were consecutively
67123), Ottawa, Ontario, Canada. Dr Pibarot is the Director of the Canada Research
Chair in Valvular Heart Diseases, Canadian Institutes of Health Research, Ottawa, evaluated by Doppler echocardiography at the Quebec
Ontario, Canada. Medtronic Inc., St-Jude Medical Inc., and Edwards Life Science Heart Institute between January 2003 and August 2003.
Inc. have provided financial support to the Departments of Cardiac Surgery and Exclusion criteria were as follows: 1) evidence of overt
Cardiology of the Quebec Heart Institute/Laval Hospital for the clinical and
echocardiographic follow-up of patients receiving Medtronic Intact, Medtronic prosthetic valve dysfunction; 2) presence of ⬎2⫹ aortic
Mosaic, St. Jude bileaflet mechanical, and Carpentier-Edwards Perimount valves. valve regurgitation and/or ⬎ mild aortic stenosis. Seventy-
Drs. Pibarot and Dumesnil also received consultant and speaker fees from St. Jude two patients met these eligibility criteria. Measurement of
Medical and Medtronic Inc.
Manuscript received April 1, 2004; revised manuscript received July 16, 2004, systolic PA pressure and/or mitral valve EOA could not be
accepted October 14, 2004. obtained in 14 of these patients. The study group was,
JACC Vol. 45, No. 7, 2005 Li et al. 1035
April 5, 2005:1034–40 Impact of Mitral Prosthesis-Patient Mismatch
Impact of PPM on PA pressure. As expected, mitral valve 2). The indexed EOA (i.e., the degree of PPM) correlated
EOA and indexed mitral valve EOA were significantly well with postoperative PA pressures (r ⫽ 0.64; Fig. 1) and
lower in patients with PPM as compared to patients with no to a lesser extent with peak (r ⫽ 0.50) and mean (r ⫽ 0.46)
PPM. The former patients also had significantly higher gradients, and atrioventricular compliance (r ⫽ 0.37).
peak and mean transvalvular pressure gradients, PA pres- Hence, the average systolic PA pressure was significantly
sure, and prevalence of PA hypertension, whereas their net higher (p ⬍ 0.001) in patients with PPM (46 ⫾ 8 mm Hg)
atrioventricular compliance was significantly lower (Table compared to patients with no PPM (34 ⫾ 8 mm Hg) (Table
Table 2. Postoperative Doppler Echocardiographic Data
All Patients No PPM PPM
Variables (n ⴝ 56) (n ⴝ 16) (n ⴝ 40) p Value
Atrial fibrillation 22 (39%) 7 (44%) 15 (38%) NS
End-diastolic LV diameter (mm) 49 ⫾ 7 50 ⫾ 7 49 ⫾ 7 NS
End-systolic LV diameter (mm) 34 ⫾ 9 34 ⫾ 9 33 ⫾ 8 NS
End-diastolic interventricular septal thickness (mm) 10 ⫾ 2 10 ⫾ 1 10 ⫾ 2 NS
End-diastolic LV posterior wall thickness (mm) 10 ⫾ 2 10 ⫾ 3 11 ⫾ 2 NS
End-systolic LA diameter (mm) 51 ⫾ 11 52 ⫾ 14 50 ⫾ 10 NS
Mitral valve EOA (cm2) 1.8 ⫾ 0.4 2.3 ⫾ 0.3 1.7 ⫾ 0.3 ⬍0.001
Indexed mitral valve EOA (cm2/m2) 1.1 ⫾ 0.3 1.4 ⫾ 0.1 1.0 ⫾ 0.2 ⬍0.001
Peak transmitral gradient (mm Hg) 11 ⫾ 4 8⫾2 12 ⫾ 4 ⬍0.001
Mean transmitral gradient (mm Hg) 4⫾2 3⫾1 4⫾2 0.001
Net atrioventricular compliance (ml/mm Hg) 4.1 ⫾ 1.7 5.3 ⫾ 1.6 3.6 ⫾ 1.6 0.001
Systolic PA pressure (mm Hg) 42 ⫾ 10 34 ⫾ 8 46 ⫾ 8 ⬍0.001
PA hypertension (systolic PA pressure ⬎40 mm Hg) 30 (54%) 3 (19%) 27 (68%) 0.001†
Symbols as in Table 1.
EOA ⫽ effective orifice area; LA ⫽ left atrial; LV ⫽ left ventricular; PA ⫽ pulmonary arterial; PPM ⫽ prosthesis-patient mismatch.
JACC Vol. 45, No. 7, 2005 Li et al. 1037
April 5, 2005:1034–40 Impact of Mitral Prosthesis-Patient Mismatch
Figure 1. Correlation between systolic pulmonary arterial (PA) pressure Figure 3. Correlation between systolic pulmonary arterial (PA) pressure
and indexed mitral valve effective orifice area. An indexed mitral valve and net atrioventricular compliance.
effective orifice area ⱕ1.2 cm2/m2 afforded the best sensitivity and
specificity for the prediction of PA hypertension defined as a systolic PA
pressure ⬎40 mm Hg (thin lines). followed by atrioventricular compliance. Mean transvalvular
flow rate had a minimal contribution with borderline
2). Likewise, the prevalence of persistent PA hypertension significance. There was a weak (r ⫽ 0.35, p ⫽ 0.007)
after MVR was 68% in patients with PPM versus 19% in correlation between time to follow-up and postoperative PA
patients with no PPM (Fig. 2). An indexed mitral valve pressure in univariate analysis, but this variable was not a
EOA ⱕ1.2 cm2/m2 had a sensitivity of 68% and a specificity significant independent predictor of PA pressure in multi-
of 81% to predict PA hypertension.
variate analysis.
Impact of atrioventricular compliance on PA pressure. Sys-
In the subgroup of 48 patients in whom the preoperative
tolic PA pressure also correlated (r ⫽ 0.53) with net
PA pressure was available, this variable did not come out as
atrioventricular compliance (Fig. 3). On average, patients
a significant predictor of postoperative PA pressure in
with an atrioventricular compliance ⱕ4 ml/mm Hg had a
significantly higher (p ⬍ 0.001) postoperative systolic PA multivariate analysis, and the only significant predictors
pressure (46 ⫾ 8 mm Hg) compared to those with compli- were the indexed MVA (⌬R2 ⫽ 0.39, p ⫽ 0.003) and the
ance ⬎4.0 ml/mm Hg (36 ⫾ 8 mm Hg). net atrioventricular compliance (⌬R2 ⫽ 0.08, p ⫽ 0.01).
Independent determinants of PA pressure. In multivari- In Figure 4, the patients were separated into four sub-
ate analysis, the independent determinants of systolic PA groups depending on the presence of PPM and of low
pressure were: indexed mitral valve EOA (p ⬍ 0.001), net atriocompliance defined as being ⱕ4.0 ml/mm Hg. The
atrioventricular compliance (p ⬍ 0.001), and mean trans- systolic PA pressure and prevalence of PA hypertension
valvular flow rate (p ⫽ 0.04) (Table 3). Indexed EOA had were 33 ⫾ 9 mm Hg and 23% in patients (n ⫽ 13) with no
the most important contribution in the multivariate model PPM and normal compliance, 34 ⫾ 2 mm Hg and 0% in
patients (n ⫽ 3) with no PPM and low compliance, 40 ⫾ 5
mm Hg and 36% in patients (n ⫽ 11) with PPM and
normal compliance, and 48 ⫾ 7 mm Hg and 79% in
patients (n ⫽ 29) with PPM and low compliance.
atrioventricular compliance because, according to equation factors, such as pulmonary vascular resistance or PA com-
2, the latter is always lower than either of its two compo- pliance, may also influence the normalization of PA pres-
nents (i.e., left ventricular and left atrial compliances). In sure after MVR. However, these factors are difficult to
patients with native mitral valve stenosis, Schwammenthal estimate by Doppler-echocardiography, and they were in-
et al. (19) demonstrated that atrioventricular compliance is deed not measured in this study. Nonetheless, it should also
an important physiological modulator of left atrial and PA be considered that, as opposed to PPM, these factors are
pressures. In the context of MVR, it, however, becomes hardly preventable or modifiable. Hence, although this
evident that compliance is also influenced by PPM. This information could be used to evaluate postoperative out-
observation appears to be confirmed by the results of come, it could not contribute to the development of a
univariate and multivariate analysis (Table 3), whereby, in prospective strategy that would optimize the regression of
univariate analysis, PPM (i.e., indexed EOA) accounts for PA hypertension after MVR.
41% of the variance of PA pressure compared to 28% for Conclusions. Persistent PA hypertension is frequent after
compliance, whereas, in multivariate analysis, the indepen- MVR and strongly associated with the presence of valve
dent contribution of PPM remains at 41%, but that of PPM. The clinical implications of these findings are impor-
compliance decreases to 10%, suggesting that compliance is tant given that PPM may be avoided by using a simple
indeed influenced by PPM. Also consistent with this prospective strategy at the time of operation.
observation is the fact that reduced atrioventricular compli-
ance had a minimal effect on PA pressure in the absence of Acknowledgments
PPM, whereas the combination of PPM and low atrioven- The authors thank Isabelle Laforest, Dominique Labrèche,
tricular compliance was associated with a dramatic increase Julie Martin, Brigitte Dionne, and Julien Magne for their
in the prevalence of PA hypertension (Fig. 4). Hence, it technical assistance in the realization of the study.
would appear that a decrease in atrial compliance may be
relatively well tolerated in patients with a prosthetic valve Reprint requests and correspondence: Dr. Philippe Pibarot,
with a large EOA and no PPM but that the same condition Laval Hospital, 2725 Chemin Sainte-Foy, Sainte-Foy, Quebec,
may be much less well tolerated in patients with a relative Canada, G1V 4G5. E-mail: philippe.pibarot@med.ulaval.ca.
obstruction to flow due to the prosthesis.
Clinical implication. The clinical implications of these
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