Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement
Background—Surgical aortic root enlargement (ARE) during aortic valve replacement (AVR) allows for larger prosthesis implantation and may be an important adjunct to surgical AVR in the transcatheter valve-in-valve era. The incremental operative risk of adding ARE to AVR has not been established. We sought to evaluate the early outcomes of patients undergoing AVR with or without ARE.
Methods—From January 1990 to August 2014, 7039 patients underwent AVR (AVR + ARE, n=1854; AVR, n=5185) at a single institution. Patients with aortic dissection and active endocarditis were excluded. Mean age was 65±14 years and 63% were male. Logistic regression and propensity score matching were used to adjust for unbalanced variables in group comparisons.
Results—Patients undergoing AVR + ARE were more likely to be female (46% vs. 34%, p<0.001) and had higher rates of previous cardiac surgery (18% vs 12%, p<0.001), COPD (5% vs. 3%, p=0.004), urgent/emergent status (6% vs 4%, p=0.01), and worse NYHA status (p<0.001). Most patients received bioprosthetic valves (AVR + ARE: 73.4% vs. AVR: 73.3%, p=0.98) and also underwent concomitant cardiac procedures (AVR+ARE: 68% vs. AVR: 67%, p=0.31). Mean prosthesis size implanted was slightly smaller in patients requiring AVR + ARE vs. AVR (23.4±2.1 vs. 24.1±2.3, p<0.001). In-hospital mortality was higher following AVR + ARE (4.3% vs. 3.0%, p=0.008), although when the cohort was restricted to patients undergoing isolated aortic valve replacement with or without root enlargement, mortality was not statistically different (AVR + ARE: 1.7% vs. AVR: 1.1%, p=0.29). Following adjustment for baseline characteristics, AVR + ARE was not associated with an increased risk of in-hospital mortality when compared with AVR (Odds Ratio 1.03, 95% CI (0.75-1.41), p=0.85). Furthermore, AVR + ARE was not associated with an increased risk of post-operative adverse events. Results were similar if propensity matching was used instead of multivariable adjustments for baseline characteristics.
Conclusions—In the largest analysis to date, ARE was not associated with increased risk of mortality or adverse events. Surgical ARE is a safe adjunct to AVR in the modern era.
- Received July 13, 2017.
- Revision received October 23, 2017.
- Accepted November 3, 2017.