Long-Term Survival Following Aortic Valve Replacement: the Influence of Age, Prosthesis-Patient Mismatch and Indexed Effective Orifice Area

Alexander Manché, Aaron Casha, Liberato Camilleri



Prosthesis-patient mismatch (PPM) has been linked to reduced long-term survival after aortic valve replacement. We studied the influence of age, PPM and indexed effective orifice area (iEOA) in this setting.



Patients (n=586) subjected to aortic valve replacement were followed up for a mean of 7.8 years (maximum 20 years). The study population was divided into four equivalent groups according to age. Mortality data was extracted from the National Statistics database. Data pertaining to patient body surface area and valve effective orifice area was collected prospectively and mismatch (moderate or severe) was defined according to established values. The Cox proportional hazard model was used to study the effect of age, mismatch and iEOA on survival. The Log Rank test was used to compare survival curves by age groups.



The incidence of moderate PPM was 24.6%, and of severe PPM 3.9%. Mismatch increased the hazard of death by 31.2% for moderate PPM and 70.3% for severe PPM but did not reach statistical significance. Mean age of patients with mismatch (n=167) was 2.52 years less than in those without (63.35±10.61 versus 65.87±11.69, p=0.016). Age significantly affected survival, increasing the risk of death by 7.3% for every incremental year.  Mean iEOA was 0.94±0.15cm2/m2; for every 0.1unit increase in iEOA the risk of death decreased by 8.8%.



Long-term survival was significantly affected by age at operation.  Although mismatch increased hazard of death the effect did not reach statistical significance. A larger iEOA had a significant beneficial effect on survival.


long-term survival; aortic valve replacement; age; prosthesis-patient mismatch; indexed effective orifice area

Full Text:



Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation 1978;58:20-24. https://doi.org/10.1161/01.CIR.58.1.20

Zoghbi WA, Chambers JB, Dumesnil JG, Foster E, Gottdiener JS, Grayburn PA et al. Recommendations for evaluation of prosthetic valves with echocardiography and Doppler ultrasound. J Am Soc Echocardiograph 2009;9:975-1014. http://dx.doi.org/10.1016/j.echo.2009.07.013



Pibarot P, Dumesnil JG, Lemieux M, Cartier P, Metras J, Durand LG. Impact of prosthesis-patient mismatch on hemodynamic and symptomatic status, morbidity and mortality after aortic valve replacement with a bioprosthetic heart valve. J Heart Valve Dis 1998;7:211-218.

Cohen RG, Bourne ET. Industry-generated charts for the selection of stented aortic valve prostheses: clinical tool or marketing ploy? Ann Thorac Surg 2011;91:1001-1002. http://dx.doi.org/10.1016/j.athoracsur. 2011.01.051

Dumesnil JG, Honos GN, Lemieux M, Beauchemin J. Validation and applications of indexed aortic prosthetic valve areas calculated by Doppler echocardiography. J Am Coll Cardiol 1990;16:637-643. http://dx.doi.org/10.1016/0735-1097(90)90355-S

Gillinov AM, Blackstone EH, Alster JM, Craver JM, Baumgartner WA, Brewster SA, Kleinman LH, Smedira NG. The CarboMedics Top Hat supra-annular aortic valve: a multicenter study. Ann Thorac Surg 2003;75:1175-1180.

Jamieson WR, Koerfer R, Yankah CA, Zittermann A, Hayden RI, Ling H, Hetzer R, Dolman WB. Mitroflow aortic pericardial bioprosthesis – clinical performance. Eur J Cardiothorac Surg 2009;36:818-824. http://dx.doi.org/10.1016/j.ejcts.2009.05.020

Pibarot O, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006;92:1022-1029. http://dx.doi.org/10.1136/hrt.2005.067363

Tasca G, Mhagna Z, Perotti S, Centurini PB, Sabatini T, Amaducci A, Brunelli F, Cirillo M, Dalla Tomba M, Quaini E, Troise G, Pibarot P. Impact of prosthesis-patient mismatch on cardiac events and midterm mortality after aortic valve replacement in patients with pure aortic stenosis. Circulation 2006;113:570-576. http://dx.doi.org/10.1161/CIRCULATIONAHA.105.587022

Flameng W, Herregods MC, Vercalsteren M, Herijgers P, Bogaerts K, Meuris B. Prosthesis-patient mismatch predicts structural valve degeneration in bioprosthetic heart valves. Circulation 2010;121:2123-2129. http://dx.doi.org/10.1161/CIRCULATIONAHA.109.901272

Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000;36:1131-1141. http://dx.doi.org/10.1016/S0735-1097(00)00859-7

Blackstone EH, Cosgrove DM, Jamieson WR, Birkmeyer NJ, Lemmer JH jr, Miller DC, Butchart EG, Rizzoli G, Yacoub M, Chai A. Prosthesis size and long-term survival after aortic valve replacement. J Thorac Cardiovasc Surg 2003;126:783-796. http://dx.doi.org/10.1016/S0022-5223(03)00591-9

Asimakopoulos G, Edwards MB, Taylor KM. Aortic valve replacement in patients 80 years of age and older. Survival and cause of death based on 1100 cases: Collective results from the UK Heart Valve Registry. Circulation 1997;96:3403-3408. http://dx.doi.org/10.1161/01. CIR.96.10.3403

Brennan JM, Edwards FH, Zhao Y, O’Brien SM, Douglas PS, Peterson ED on behalf of the Developing Evidence to Inform About Effectiveness – Aortic Valve Replacement (DEcIDE AVR) research team. Long-term survival after aortic valve replcement among high-risk elderly patients in the United States. Insights from the Society of Thoracic Surgeons Adult Cardiac Surgery Database, 1991 to 2007. Circulation 2012;126:1621-1629. http://dx.doi.org/10.1161/CIRCULATIONAHA.112.091371

Mrowczynski W, Lutter G, Attmann T, Hoffmann G, Quaden R, Cremer J, Boning A. Does patient-prosthesis mismatch influence the results of combined aortic valve replacement and coronary bypass grafting? Kardiol Pol 2009;67:865-873.

Chambers J, Cross J, Deverall P, Sowton E. Echocardiographic description of the CarboMedics bileaflet prosthetic heart valve. J Am Coll Cardiol 1993;21:398-405. http://dx.doi.org/10.1016/0735-1097(93)90681-P

Mosquera VX, Bouzas-Mosquera A, Bautista-Hernandez V, Estévez-Cid F, Herrera-Noreña JM, Alvarez-García N, Cuenca-Castillo JJ. The CarboMedics supra-annular Top Hat valve improves long-term left ventricular mass regression. J Thorac Cardiovasc Surg 2014;148:2845-2853. http://dx.doi.org/10.1016/j.jtcvs.2014.06.082

Wiseth R, Levang DW, Sande E, Tangen G, Skjaerpe T, Hatle L. Hemodynamic evaluation by Doppler echocardiography of small (≤21mm) prostheses and bioprostheses in the aortic valve position. Am J Cardiol 1992;70:240-246.

Botzenhardt F, Eichinger WB, Guenzinger R, Bleiziffer S, Wagner I, Bauernschmitt R, Lange R. Hemodynamic performance and incidence of patient-prosthesis mismatch of the complete supraannular perimount magna bioprosthesis in the aortic position. The Thoracic and Cardiovascular Surgeon 2005;53:226-230. http://dx.doi.org/10.1055/s-2005-837678

Bleiziffer S, Eichinger WB, Hettich IM, Ruzicka D, Badiu CC, Guenzinger R, Bauernschmitt R, Lange R. Hemodynamic characterization of the Sorin Mitroflow pericardial bioposthesis at rest and exercise. J Heart Valve Dis 2009;18:95-100.

Jamieson WR, Koerfer R, Yankah CA, Zittermann A, Hayden RI, Ling H, et al. Mitroflow aortic pericardial bioprosthesis – clinical performance. Eur J Cardiothorac Surg 2009;36:818-824. http://dx.doi.org/10.1016/j.ejcts.2009.05.020

Yankah CA, Pasic M, Musci M, Stein J, Detschades C, Siniawski H, Hetzer R. Aortic valve replacement with the Mitroflow pericardial bioprosthesis: durability results up to 21 years. J Thorac Cardiovasc Surg 2008;136:688-696. http://dx.doi.org/10.1016/j.ejcts.2008.05.022

Del Rizzo DF, Goldman BS, Christakis GT, David TE. Hemodynamic benefits of the Toronto stentless valve. J Thorac Cardiovasc Surg 1996;112:1431-1445. http://dx.doi.org/10.1016/S0022-5223(96)70001-6

Head SJ, Mokhles MM, Osnabrugge RL, Pibarot P, Mack MJ, Takkenberg JJ, Bogers AJ. The impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement: a systematic review and meta-analysis of 34 observational studies comprising 27186 patients with 133141 patient-years. Eur Heart J 2012;33:1518-1529. http://dx.doi.org/10.1093/eurheartj/ehs003

Tsutsumi K, Nagumo M, Nishikawa K, Takahashi R. Effect of prosthesis-patient mismatch on survival after aortic valve replacement using mechanical prostheses in patients with aortic stenosis. Gen Thorac Cardiovasc Surg 2008;56:577-583. http://dx.doi.org/10.1007/s11748-008-0317-9

Frapier JM, Rouviere P, Razcka F, Aymard T, Albat B, Chaptal PA. Influence of patient-prosthesis mismatch on long-term results after aortic valve replacement with a stented bioprosthesis. J Heart Valve Dis 2002;11:543-551.

Manché A, Camilleri L, Gauci D. Dies aortic valve replacement restore normal life expectancy: a twenty-year relative survival study. International Cardiovascular Forum Journal 2016;6:46-53. http://dx.doi.org/10.17987/icfj.v6i0.138

Kulik A, Al-Saigh M, Chan V, Masters RG, Bedard P, Lam BK, et al. Enlargement of the small aortic root during aortic valve replacement: is there a benefit? Ann Thorac Surg 2008;85:94-100. http://dx.doi.org/10.1016/j.athoracsur.2007.07.058

Shewan LG, Coats AJS, Henein M. Requirements for ethical publishing in biomedical journals. International Cardiovascular Forum Journal 2015;2:2 DOI:10.17987/icfj.v2i1.4

DOI: http://dx.doi.org/10.17987/icfj.v11i0.432

Copyright (c) 2017 The authors

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.