Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch

doi:10.1016/S0003-4975(02)03680-9

The Annals of Thoracic Surgery

Volume 74, Issue 1, July 2002, Pages 31-36

Presented at the Forty-eighth Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 8–10, 2001.

https://doi.org/10.1016/S0003-4975(02)03680-9 Get rights and content

Abstract

Background. We routinely use aortic root enlargement (ARE) as part of one strategy to avoid prosthesis-patient mismatch in patients with relatively small aortic roots who are undergoing aortic valve replacement (AVR).

Methods. We performed a retrospective review of 657 consecutive stented AVR patients at a single institution between 1995 to 2001. Of these, 114 (17%) patients underwent ARE. Root enlargement was selectively performed in patients at risk for prosthesis-patient mismatch, defined as calculated projected indexed effective orifice area (iEOA) less than 0.85 cm²/m². This involved extension of the aortotomy between the left and noncoronary cusps, valve implantation, and Dacron patch closure of the aorta, thus permitting replacement with a valve size appropriate to body surface area.

Results. The mean age of ARE patients was 72.5 ± 11.0 years, with 32% aged 80 years or more. Of the patients, 61% were female and 27% had undergone previous cardiac operations. Combined procedures included coronary bypass in 57 patients and mitral repair or replacement in 24. The prevalence of mismatch was less than 3%. The ARE required an average of 19 minutes of additional aortic clamp time. The 30-day mortality was 0.9%. Logistic regression showed perfusion time to be the only independent predictor of mortality.

Conclusions. Our results show that ARE can be performed readily and with minimal added risk relative to standard AVR. We also present a preventive strategy to minimize mismatch predicted at time of operation from the reference value of effective orifice area for a given prosthesis and the patient’s size. This includes use of ARE to enhance the potential benefit of AVR.

Section snippets

Patient population

We examined the clinical records of 852 consecutive adult patients in whom we performed aortic valve procedures (isolated and combined) from January 1, 1995, through June 30, 2001, at a single institution. Of this group, 195 patients underwent stentless aortic valve replacement or aortic root reconstruction for a variety of indications, and will not be considered further. The remaining 657 patients underwent stented aortic valve replacement either with (all ARE, 114 patients, 17%) or without

Results

The distribution of labeled valve sizes is demonstrated graphically in Figure 2 and summarized in Table 3. The mean labeled aortic valve size was 23.9 ± 2.2 in all AVR patients and 23.2 ± 1.7 in all ARE patients. The median labeled size in both groups was 23 mm. A prosthesis labeled 23 mm or larger was used in 75% of the all ARE patients. A valve size labeled 19 was implanted in 1 (0.9%) ARE patient. This was a unique case requiring enlargement of a “nickel-sized” annulus in an adult to

Comment

This review demonstrates that stented aortic valve replacement can be performed without causing prosthesis-patient mismatch in the vast majority (>97%) of patients who undergo operation. It also demonstrates that aortic root enlargement by the method described adds about 20 minutes of aortic clamp time, but adds no increase in morbidity or early mortality. In fact, we have long considered this technique a simple way to add value to aortic valve replacement and an alternate method of closing the

Acknowledgements

We acknowledge the assistance and expertise of Peter Dolan, who provided us with the anatomical illustrations.

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Cited by (132)

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography
2024, Journal of the American Society of Echocardiography
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
Outcomes of Root Enlargement vs Root Replacement for Aortic Stenosis
2023, Annals of Thoracic Surgery
Stentless aortic root replacement (ARR) and aortic root enlargement (ARE) are established strategies to avoid prosthesis-patient mismatch in patients with aortic stenosis (AS) and small annuli. We sought to compare outcomes of these 2 procedures.
This was an observational study using an institutional database of aortic valve replacements from 2010 to 2021. The study compared patients who underwent ARE vs ARR for AS. Those with endocarditis or aortic aneurysms were excluded. Postoperative outcomes were compared between groups. Kaplan-Meier survival estimation and multivariable Cox regression for survival were performed. Cumulative incidence functions were generated for all-cause readmissions.
A total of 533 patients underwent either ARE or ARR for AS. Of these, 193 (36.2%) underwent ARE and 340 (63.8%) underwent ARR with a stentless xenograft. There were no significant differences in operative mortality, stroke, length of stay, or new-onset renal failure requiring dialysis. There were also no significant differences in aortic valve reintervention rates (3.1% vs 1.8%; P = .314). Patients in the ARR group had larger valves implanted, larger indexed effective orifice areas, lower rates of prosthesis-patient mismatch, and lower transprosthetic gradients (P < .001). Median follow-up was 5.02 (2.70-7.8) years. Kaplan-Meier survival estimates were comparable, and on multivariable Cox regression, ARR vs ARE was not significantly associated with an increased hazard of death (hazard ratio, 1.00; 95% CI, 0.69-1.45; P = .996). Cumulative incidence estimates for all-cause readmissions were also comparable between groups.
ARE and stentless xenograft ARR for AS were associated with comparable postoperative complications, aortic valve reinterventions, freedom from readmission, and 5-year survival.
Surgical valve selection in the era of transcatheter aortic valve replacement in the Society of Thoracic Surgeons Database
2020, Journal of Thoracic and Cardiovascular Surgery
Time trends in surgical valve selection have not been explored in detail in the era of transcatheter aortic valve replacement (TAVR) in nationally representative data. Herein, we explore valve selection trends in the TAVR era using the Society of Thoracic Surgeons Adult Cardiac Surgery Database.
Isolated first-time biological or mechanical aortic valve replacements (AVR) from 2004 to 2016 in the Society of Thoracic Surgeons Adult Cardiac Surgery Database were included. Patient characteristics were examined in the pre-TAVR era (2004-2007) and the post-TAVR era (2008-2016) using the year 2007 as the cut-point. Using a piece-wise regression analysis to model the relationship between time and type of valve used, a change-point analysis was performed to empirically determine the time of change in practice, both overall and in age-specific subgroups (≤60 years and >60 years).
In total, 214,390 patients underwent isolated primary mechanical or biological AVR from 2004 to 2016. The patients' mean age increased slightly between the 2 eras (67.1 vs 68.6 years, P < .001), whereas the proportion of mechanical AVRs decreased (24.8% vs 12.2%, P < .001). Piece-wise regression demonstrated that the proportion of mechanical valves decreased over time. An empirically estimated slope change-point was found after the first quarter 2010; from 2004 to 2009, the overall proportion of mechanical valves was decreasing quickly (−2.81%/year, 95% confidence interval [95% CI], −3.03% to −2.60%), compared with 2010 to 2016. The early decline was steeper for younger patients (−4.21%/year, 95% CI, −4.74 to −3.69) compared with older patients (−1.44%/year, 95% CI −1.64 to −1.23).
Use of mechanical AVR declined significantly from 2004 to 2016 and was decreasing before the introduction or the approval of TAVR in the United States.
Incremental Risk of Annular Enlargement: A Multi-Institutional Cohort Study
2019, Annals of Thoracic Surgery
Annular enlargement (AE) is a critical technique to avoid patient-prosthesis mismatch and may help facilitate future valve-in-valve (ViV) transcatheter replacement. We hypothesized that the addition of annular enlargement would increase risk of morbidity and mortality and that the number of annular enlargement procedures is increasing to accommodate future ViV procedures.
Patients undergoing aortic valve replacement ± coronary surgery (2012 to 2017) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by annular enlargement and era, pre-ViV (2012 to 2014) vs ViV (2015 to 2017) for univariate analysis. Risk-adjusted outcomes were assessed by hierarchical regression modeling adjusting for predicted risk of mortality.
Of 6045 patients, the 300 (5.0%) who received an annular enlargement were younger and more commonly female. Patients receiving an annular enlargement had higher complication rates including operative mortality (4.7% vs 2.5%, P = .024). After risk adjustment, AE was independently associated with increased mortality (odds ratio, 2.06, P = .016) and major morbidity (odds ratio, 1.41, P = .042). The rate of enlargement increased from 3.9% pre-ViV to 6.3% ViV (P < .001). The use of ViV capable valves (bioprosthetic ≥23 mm) from 61% to 67% (P = .001), and more in AE patients (30% vs 11% non-AE). Alternatively, the rate of patient prosthesis mismatch declined from 23% to 16%.
Increasing utilization of AE coincides with a decline in patient prosthesis mismatch and may facilitate future ViV transcatheter aortic valve replacement. However, AE was independently associated with increased morbidity and mortality. High variability in AE volume may be increasing risk and deserves further investigation.
Commentary: Porcine bioprosthetic root replacement for aortic stenosis: Farcical or sensible?
2019, Journal of Thoracic and Cardiovascular Surgery
Aortic Root Enlargement Is Safe and Reduces the Incidence of Patient-Prosthesis Mismatch: A Meta-analysis of Early and Late Outcomes
2019, Canadian Journal of Cardiology
Aortic root enlargement (ARE) may be an important adjunct to aortic valve replacement (AVR) to prevent patient-prosthesis mismatch and facilitate future valve-in-valve transcatheter AVR (TAVR). However, the early safety and late benefits of adding surgical ARE to AVR remain controversial.
MEDLINE and EMBASE were searched from 1946 to 2018 for articles comparing patients undergoing AVR+ARE with those undergoing AVR alone. A random-effects meta-analysis was performed to compare early and late clinical outcomes.
A total of 2570 AVR+ARE and 5,991 AVR patients were included from 9 observational studies. There was no difference in early mortality (relative risk [RR] 1.21; 95% confidence interval [CI], 0.94-1.54; P = 0.13). Both cardiopulmonary bypass (mean difference [MD] 20 minutes; 95% CI, 15-25; P < 0.01) and aortic cross-clamp time (MD 14 minutes; 95% CI, 11-17, P < 0.01) were higher following AVR+ARE. There was no difference in the risk of permanent pacemaker implantation (RR 1.02; 95% CI, 0.83-1.25; P = 0.86), reoperation for bleeding (RR 1.05; 95% CI, 0.84-1.32; P = 0.64), or stroke (RR 0.93; 95% CI, 0.68-1.27; P = 0.65). The risk of moderate (indexed effective orifice area [iEOA] < 0.85 cm²/m²) and severe (iEOA < 0.65 cm²/m²) patient-prosthesis mismatch (PPM) was lower with AVR+ARE (RR 0.65; 95% CI, 0.51-0.83; P < 0.01) and RR 0.36; 95% CI, 0.16-0.82; P = 0.01, respectively). There was no difference in late mortality (incidence rate ratio [IRR] 1.05; 95% CI, 0.87-1.27; P = 0.59) at mean 7.8-year follow-up in 5 studies.
Surgical ARE is a safe adjunct to AVR in selected patients that does not increase early adverse events and results in less patient-prosthesis mismatch. This strategy allows for a larger valve size at the time of implantation, an important consideration for potential future valve-in-valve procedures in the era of TAVR.
La dilatation de la racine aortique (DRA) peut être un complément important au remplacement valvulaire aortique (RVA) pour prévenir la disproportion patient-prothèse et faciliter le RVA de type valve-in-valve par cathéter (RVAC). Toutefois, l’innocuité initiale et les avantages tardifs de l’ajout de la DRA au RVA demeurent controversés.
Nous avons consulté MEDLINE ET EMBASE pour trouver des articles entre 1946 et 2018 qui portaient sur la comparaison des patients qui subissaient des RVA+DRA aux patients qui subissaient seulement un RVA. Nous avons réalisé une méta-analyse à effets aléatoires pour comparer les résultats précoces et tardifs.
Nous avons retenu un total de 2570 RVA+DRA et 5991 patients ayant subi un RVA qui provenaient de 9 études observationnelles. Nous n’avons observé aucune différence dans la mortalité précoce (risque relatif [RR] 1,21; intervalle de confiance [IC] à 95 %, 0,94-1,54; P = 0,13). La durée du pontage cardiopulmonaire (différence moyenne [DM] de 20 minutes; IC à 95 %, 15-25; P < 0,01) et la durée de clampage aortique (DM de 14 minutes; IC à 95 %, 11-17, P < 0,01) étaient plus élevées après les RVA+DRA. Nous n’avons noté aucune différence dans le risque d’implantation permanente d’un stimulateur cardiaque (RR 1,02; IC à 95 %, 0,83-1,25; P = 0,86), de réintervention chirurgicale en raison d’hémorragie (RR 1,05; IC à 95 %, 0,84-1,32; P = 0,64) ou d’accident vasculaire cérébral (RR 0,93; IC à 95 %, 0,68-1,27; P = 0,65). Le risque de disproportion patient-prothèse (DPP) modérée (surface fonctionnelle de l’orifice indexée [SFOi] < 0,85 cm²/m²) et de DPP importante (SFOi < 0,65 cm²/m²) était plus faible lors de RVA+ DRA (RR 0,65; IC à 95 %, 0,51-0,83; P < 0,01) et RR 0,36; IC à 95 %, 0,16-0,82; P = 0,01, respectivement). Nous n’avons noté aucune différence dans la mortalité tardive (rapport de taux d’incidence [RTI] 1,05; IC à 95 %, 0,87-1,27; P = 0,59) au suivi moyen de 7,8 ans de 5 études.
La DRA chirurgicale est un complément au RVA chez les patients sélectionnés qui ne fait pas augmenter les événements indésirables précoces et entraîne moins de disproportion patient-prothèse. Cette stratégie permet une taille valvulaire plus grande au moment de l’implantation, un aspect important pour les interventions éventuelles de type valve-in-valve à l’ère du RVAC.

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Original article: cardiovascularRoutine enlargement of the small aortic root: a preventive strategy to minimize mismatch

Abstract

Section snippets

Patient population

Results

Comment

Acknowledgements

J Am Coll Cardiol

Chest

J Am Coll Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original article: cardiovascular
Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch