Aortic Annular Enlargement vs Isolated Aortic Valve Replacement in Patients With Matched Annulus

Alexander Makkinejad; Katelyn Monaghan; Sarah A Chen; Xiaoting Wu; Carol Ling; Karen Kim; Shinichi Fukuhara; Himanshu J Patel; Francis Pagani; G Michael Deeb; Bo Yang

doi:10.1016/j.athoracsur.2024.07.022

Aortic Annular Enlargement vs Isolated Aortic Valve Replacement in Patients With Matched Annulus

Ann Thorac Surg. 2024 Aug 3:S0003-4975(24)00636-2. doi: 10.1016/j.athoracsur.2024.07.022. Online ahead of print.

Authors

Affiliations

¹ Department of Surgery, UF Health, University of Florida, Gainesville, Florida.
² Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
³ Department of Surgery, UC Davis Health, University of California Davis, Sacramento, California.
⁴ Division of Cardiovascular & Thoracic Surgery, Department of Surgery and Perioperative Care, University of Texas at Austin, Austin, Texas.
⁵ Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address: [email protected].

PMID: 39102933
DOI: 10.1016/j.athoracsur.2024.07.022

Abstract

Background: We aimed to determine the effect of aortic annular enlargement on the midterm outcomes of aortic valve replacement surgery by comparing patients with the same-sized (≤23 mm) native aortic annuli.

Methods: From January 2011 to June 2022, 1328 patients underwent isolated aortic valve replacement-1163 without aortic annular enlargement (AVR group) and 165 with aortic annular enlargement (AVR+AAE group). Propensity score matching identified 112 pairs, controlling for native aortic annulus diameter, age, sex, diabetes, chronic lung disease, dialysis, ejection fraction, prior cardiac surgery, indication, hypertension, dyslipidemia, valve type, prior stroke, prior myocardial infarction, and case status.

Results: Demographic and preoperative variables were similar, except body surface area was larger in the AVR+AAE group (2.1 m² vs 1.9 m²). Median native aortic annulus diameter was 23 mm in both groups. Median prosthesis size was 25 in the AVR+AAE group and 23 in the AVR group. The AVR+AAE group had longer cardiopulmonary bypass (143 vs 111 minutes) and cross-clamp (115 vs 82 minutes) times. Incidences of perioperative complications, including operative mortality (1.8% AVR+AAE vs 3.6% AVR) were similar between groups. Survival at 6 years was 98% in the AVR+AAE group and 74% in the AVR group (P = .016). Aortic annular enlargement was an independent protective factor for midterm mortality, with a hazard ratio of 0.19 (P = .006). The rate of moderate/severe patient-prosthesis mismatch was 19% in the AVR+AAE group and 31% in the AVR group (P = .16).

Conclusions: Patients with small native aortic annuli (≤23 mm) undergoing isolated aortic valve replacement may benefit from aortic annular enlargement.