Thorac cardiovasc Surg 2014; 62(06): 463-468
DOI: 10.1055/s-0034-1377063
Review Article
Georg Thieme Verlag KG Stuttgart · New York

Novel Thoughts on Patient–Prosthesis Mismatch in Aortic Valve Replacement: The Rationale for the PAR I Trial

Torsten Doenst
1  Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
Paulo A. Amorim
1  Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
Mahmoud Diab
1  Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
Andreas Hagendorff
2  Department of Cardiology and Angiology, University of Leipzig, Leipzig, Germany
,
Gloria Faerber
1  Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University, Jena, Germany
,
Jürgen Graff
3  Department of Vardiac Surgery, Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg, Germany
,
Ardawan Rastan
3  Department of Vardiac Surgery, Center of Cardiovascular Diseases Rotenburg a. d. Fulda, Rotenburg, Germany
,
Oliver Deutsch
4  Department of Cardiac Surgery, Hospital Bogenhausen, Munich, Germany
,
Walter Eichinger
4  Department of Cardiac Surgery, Hospital Bogenhausen, Munich, Germany
,
PAR I Investigators› Author Affiliations
Further Information

Publication History

14 January 2014

31 March 2014

Publication Date:
19 August 2014 (eFirst)

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.

Note

T.D., A.R., and W.E. received honoraria from St. Jude Medical, Inc. for lectures on aortic valve topics. The PAR I trial is sponsored by St. Jude Medical, Inc. The content of this article has been presented at the annual meeting of the DGTHG 2013.