Mitral annular constraint shapes aortic prosthesis size and early hemodynamics in combined aortic and mitral valve surgery

Objective To determine whether mitral annular constraint is associated with implanted aortic prosthesis size, less favorable postoperative aortic hemodynamics, and worse clinical outcomes in patients undergoing concomitant aortic and mitral valve surgery. Methods We analyzed 651 patients undergoing combined aortic and mitral valve surgery and stratified them into those with and without annular constraint defined by anchoring sutures in the anterior mitral annulus for mitral valve replacement or repair with a complete annuloplasty ring. Primary outcomes included aortic prosthesis size, postoperative transvalvular gradient, indexed effective orifice area (EOAi), and moderate or severe prosthesis-patient mismatch (PPM). Secondary outcomes were perioperative morbidity and late survival. Results Annular constraint was associated with implantation of a smaller aortic prosthesis (median 23 vs. 25 mm; p < 0.001), a higher prevalence of moderate or severe PPM (33.3% vs. 21.9%; p=0.005) and a smaller EOAi (1.0 vs. 1.1 cm 2 /m 2 ; p < 0.001). The adjusted reduction in aortic valve gradient from preoperative to postoperative measurements was smaller in the annular constraint group (p = 0.020). The annular-constraint group also had longer cross-clamp and cardiopulmonary bypass times, greater postoperative morbidity, and lower early and late survival. Conclusions Mitral annular constraint during concomitant aortic and mitral valve surgery was associated with implantation of smaller aortic prostheses and less favorable early aortic valve hemodynamics. Differences in morbidity and survival may also reflect underlying pathology, mitral procedure type, and operative complexity.