Original article
Cardiovascular
Aortic Annular Enlargement During Aortic Valve Replacement: Improving Results With Time

https://doi.org/10.1016/j.athoracsur.2007.01.059Get rights and content

Background

Enlargement of the aortic annulus during aortic valve replacement permits insertion of a larger prosthetic valve. Previous reports suggest patch enlargement of the aortic annulus increases operative morbidity and mortality during aortic valve replacement. We compared outcomes for this procedure in a contemporary group of patients with those operated on during an earlier era, to determine whether aortic annular enlargement is still associated with worse outcomes.

Methods

We reviewed prospectively gathered data on all patients undergoing aortic valve replacement and aortic annular enlargement at our institution from 1995 to 2005 (n = 669). We compared patient outcomes from two consecutive time periods: 1995 through 2000 (n = 360) versus 2001 through 2005 (n = 309). Propensity matching adjusted for baseline differences in a secondary analysis.

Results

Operative mortality was significantly lower in the more recent surgical group (2.9% versus 7.2%; p = 0.013). The rates of perioperative myocardial infarction (1.9% versus 1.1%; p = 0.4), stroke (2.9% versus 3.3%; p = 0.8), and pacemaker implantation (9.1% versus 12.5%; p = 0.16) were similar for both groups (2001 through 2005 versus 1995 through 2000, respectively). The earlier group of patients had a higher prevalence of congestive heart failure, syncope, angina, New York Heart Association class III or IV symptoms, chronic obstructive pulmonary disease, mitral valve disease, and previous cardiac surgery. After adjusting for these baseline differences with propensity matching, the risk of perioperative death remained lower in the contemporary group (3% versus 7.5%; p = 0.04).

Conclusions

Enlargement of the aortic annulus in the modern era is a safe adjunct to aortic valve replacement, and should be considered in selected patients to avoid patient–prosthesis mismatch.

Section snippets

Patients and Methods

We reviewed prospectively collected data on all patients undergoing AVR with aortic annular enlargement at our institution from 1995 to 2005 (n = 669), including patients who had concomitant coronary artery bypass grafting or mitral or tricuspid valve surgery. Patients who had aortic annular enlargement during AVR between 1995 and 2000 (n = 360, 16% of total AVR population) were compared with a contemporary cohort of patients from 2001 to 2005 (n = 309, 21% of total AVR population). Our

Results

Table 1 illustrates the demographic differences in preoperative characteristics for patients who underwent aortic annular enlargement during AVR from 1995 to 2000 compared with 2001 to 2005. The earlier time group had a higher proportion of patients with congestive heart failure, New York Heart Association class III or IV symptoms, angina, syncope, chronic obstructive pulmonary disease, concomitant mitral valve disease, reoperation, and smaller body surface area. Because the clinical profile of

Comment

Aortic valve replacement for patients with advanced aortic valve disease reduces mortality, ameliorates exercise capacity, and promotes regression of left ventricular hypertrophy. To maximize the therapeutic benefit from AVR, an appropriately sized prosthesis should be implanted into the patient, as a prosthesis with a small EOA may result in persistence of high transvalvular pressure gradients [3, 5]. Rahimtoola [18] was the first to describe PPM based on the disparity between prosthesis and

References (26)

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