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Ann Thorac Surg. 2018 Jul;106(1):14-22. doi: 10.1016/j.athoracsur.2018.01.090. Epub 2018 Apr 6.

The Incidence and Consequence of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement.

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Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. Electronic address:
Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
Section of Cardiology, Duke University Medical Center, Durham, North Carolina.
Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.
Quebec Heart and Lung Institute, Laval University, Quebec, Canada.
Section of Pediatric Cardiac Surgery, Johns Hopkins All Children's Heart Institute, St. Petersburg, Florida.



The goal of this study was to determine the relationship of prosthesis-patient mismatch (PPM) with long-term survival and to assess whether growing concern about PPM has resulted in a decreased incidence over time.


Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, we identified 59,779 patients ≥65 years old who underwent isolated surgical aortic valve replacement (AVR) between 2004 and 2014. The degree of PPM was calculated using literature-derived effective orifice areas for commonly used valves. Outcomes to 10 years were stratified by degree of PPM.


The distribution of PPM was as follows: 35%, none (n = 21,053); 54%, moderate (n = 32,243); and 11%, severe (n = 6,483). Compared with patients with no PPM, patients with moderate or severe PPM had a significantly increased risk of readmission for heart failure (hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.09 to 1.21; HR, 1.37; 95% CI, 1.26 to 1.48) and redo AVR (HR, 1.41; 95% CI, 1.13 to 1.77; HR, 2.68; 95% CI, 2.01 to 3.56) for moderate or severe PPM, respectively. Survival was significantly worse for any degree of PPM (moderate to none: HR, 1.08; 95% CI, 1.05 to 1.12; severe to none: HR, 1.32; 95% CI, 1.25 to 1.39), with 10-year adjusted survival rates of 46%, 43%, and 35% for none, moderate, and severe, respectively (p < 0.001). The incidence of severe PPM decreased by 55% over the study period, from 13.8% in 2004 to 6.2% in 2014.


Any degree of PPM significantly decreased long-term survival and increased readmission rates for both heart failure and reoperation for AVR. Temporal trends show a significant decrease in the incidence of PPM over the past decade.

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