Abstract 1801: Aortic Root Enlargement Reduces the Incidence of Prosthesis-Patient Mismatch and Improves Outcomes in Patients with Small Aortic Roots
Objectives: Aortic root enlargement (ARE) at the time of aortic valve replacement (AVR) has been suggested for the prevention of prosthesis-patient mismatch (PPM) in patients with small aortic roots (SAR). We therefore examined hemodynamic and clinical outcomes in patients with SAR who underwent AVR with or without the use of ARE.
Methods: A cohort of 1101 consecutive patients with SAR who underwent AVR with contemporary prostheses was prospectively followed. All patients had a small aortic annulus that would have led to the insertion of an aortic prosthesis of size 21 or smaller. Of these, 929 patients underwent AVR alone while 172 underwent AVR plus ARE. Outcomes and valve hemodynamics were compared using multivariate techniques. Follow-up was 2,062 patient-years (mean 4.4±3.3 years).
Results: Patients who had AVR alone received size 19–21 aortic prostheses, yet 52% of AVR plus ARE patients received size 23 aortic prostheses. Aortic cross-clamp times were 8.0±2.5 minutes longer in the AVR plus ARE group (P = 0.001), but there was no difference in cardiopulmonary bypass duration (P = 0.2), reopening rates (P = 0.7) or perioperative mortality (P = 0.7). Postoperative trans-valvular gradients were significantly lower in the AVR plus ARE group compared to the AVR alone group (peak gradient: 28.8±15.5 versus 35.8±16.7 mmHg, P= 0.001; mean gradient: 15.3±8.9 versus 20.0±9.6 mmHg, P = 0.0003). The diameters of the aortic prostheses were significantly larger in the AVR plus ARE group (internal diameter: 18.9±1.5 versus 17.2±1.2 mm, P < 0.0001; external diameter: 27.0±2.7 versus 24.6±2.7 mm, P < 0.0001) and the indexed effective orifice areas (IEOA) after surgery were significantly greater (0.84±0.18 versus 0.78±0.16 cm2/m2, P = 0.004). The incidence of PPM was also significantly reduced in the AVR plus ARE group (IEAO ≤ 0.85 cm2/m2: 51% versus 67%, P = 0.01). Amongst operative survivors, trends towards improved survival (P = 0.07) and freedom from congestive heart failure (P = 0.19) were observed in patients treated with AVR plus ARE.
Conclusions: In patients with SAR, ARE is safe and effectively reduces postoperative gradients and the incidence of PPM. ARE should therefore be considered to improve long-term hemodynamic and clinical outcomes of SAR patients.