A comparative study of surgical treatment of small aortic root with or without aortic root enlargement using a single prosthesis type

BACKGROUND: The ideal management of aortic stenosis in patients with a small aortic root remains controversial. Reports of adverse effects of patient-prosthesis mismatch (PPM) from a small-sized valve have to be weighed against the increased morbidity and mortality of aortic root enlargement procedures. METHODS: The present study retrospectively reviewed and compared clinical data of patients with predominant aortic stenosis with small aortic root (n = 209) who underwent isolated aortic valve replacement without (AVR group, n = 162) or with aortic root enlargement (AVR + ARE group, n = 47) using a single prosthesis type between January 2002 and June 2008 to assess their effect on perioperative outcomes. RESULTS: The in-hospital mortality (4.28% in AVR + ARE vs. 3.08% in AVR group) and other perioperative outcomes were similar in both the groups. Although patients of the AVR + ARE group had a greater degree of left-ventricular (LV) mass regression (-41.3 ± 32.1 vs. -21.5 ± 37.4) in the follow-up period at 12 months, there was no significant difference in functional outcome. Patients with severe postoperative PPM (indexed effective orifice area ≤0.65 cm²/m² body surface area) showed increased perioperative mortality (9.52 vs. 1.85%) and less regression of LV mass (-13.2.8 ± 27.1 vs. -27.6 ± 31.9), higher transvalvular gradient and were more symptomatic at 12-month follow-up (New York Heart Association class 1.44 ± 0.41 vs. 1.22 ± 0.28) compared to those who were having only mild to moderate PPM (indexed effective orifice area > 0.65). CONCLUSION: ARE procedures are invaluable techniques in surgical management of small aortic root patients and can be used without significantly increasing early morbidity and mortality, particularly in those cases in which AVR with a small prosthesis will lead to severe PPM.