Facing the Small Aortic Root in Aortic Valve Replacement: Enlarge or Not Enlarge?

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. In patients with severe aortic stenosis, aortic valve replacement (AVR) should aim to implant a prosthesis of adequate size to effectively eliminate left ventricular obstruction and avoid the risk of patient–prosthesis mismatch (PPM). PPM has been demonstrated to be associated with increased mortality, decreased exercise tolerance, and reduced left ventricular mass regression after AVR for aortic stenosis.1Blais C. Dumesnil J.C. Baillot R. Simard S. Doyle D. Pibarot P. Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement.Circulation. 2006; 113: 570-576Crossref PubMed Scopus (193) Google Scholar The important paper by Tam and colleagues2Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Early and late outcomes of aortic root enlargement: a multicenter propensity score-matched cohort analysis.J Thorac Cardiovasc Surg. 2020; 160: 908-919Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar in the October 2020 issue of the Journal presents the results of a multicenter study analyzing 2 cohorts of patients, compared by propensity score matching, with or without aortic root enlargement (ARE) at time of AVR. They confirmed that ARE did not influence neither early mortality, despite longer operation times, nor survival up to 8 years, when compared with AVR alone. However, in their study there is no mention of the techniques used for ARE, which may have a different impact on the entity of annular enlargement,3Bortolotti U. Celiento M. Milano A.D. Enlargement of the aortic annulus during aortic valve replacement: a review.J Heart Valve Dis. 2014; 23: 31-39PubMed Google Scholar on the real increase of prosthetic sizes, and whether PPM was effectively eliminated or minimized. We have always been interested in the issue of PPM following AVR, and in a recent study we have shown, in agreement with Tam and colleagues,2Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Early and late outcomes of aortic root enlargement: a multicenter propensity score-matched cohort analysis.J Thorac Cardiovasc Surg. 2020; 160: 908-919Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar that ARE is a safe and effective technique that does not adversely affect operative mortality4Celiento M. Saccocci M. De Martino A. Nardi C. Faggioni L. Milano A.D. et al.Stability of aortic annulus enlargement during aortic valve replacement using a bovine pericardial patch: an 18-year clinical, echocardiographic, and angio–computed tomographic follow-up.J Thorac Cardiovasc Surg. 2014; 147: 977-983Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar; moreover, our clinical, echocardiographic, and angio–computed tomographic follow-up indicates that, when a pericardial patch is used for ARE, this procedure is extremely stable, with no aneurysm formation up to 18 years and effectively addressing the problem of PPM. In must also be emphasized that, in their population, Tam and colleagues2Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Early and late outcomes of aortic root enlargement: a multicenter propensity score-matched cohort analysis.J Thorac Cardiovasc Surg. 2020; 160: 908-919Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar report a high prevalence of tissue valves employed for AVR. In this respect, the need to avoid PPM appears even more relevant considering that PPM may accelerate structural deterioration of biological prostheses, either porcine or pericardial, influencing their long-term durability.5Blasi S. Ravenni G. Celiento M. De Martino A. Milano A.D. Bortolotti U. Durability of the Mitroflow pericardial prosthesis; influence of patient-prosthesis mismatch and new anticalcification treatment.Thorac Cardiovasc Surg. 2020; 68: 131-140Crossref PubMed Scopus (2) Google Scholar There is currently enough evidence that ARE represents an important adjunct to the surgical armamentarium and that it should receive more widespread acceptance; on the other hand, use of small-sized bioprostheses for AVR should be discouraged, also in view of possible future valve-in-valve procedures. The experience by Tam and colleagues2Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Early and late outcomes of aortic root enlargement: a multicenter propensity score-matched cohort analysis.J Thorac Cardiovasc Surg. 2020; 160: 908-919Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar is clearly in favor of ARE during AVR. Despite the increasing use of new bioprosthetic models, such as the rapid deployment or sutureless devices, we feel that ARE should be still taught to the young generations so that they can grow eliminating at least one of the many Hamletic doubts with which cardiac surgeons are daily faced. Early and late outcomes following aortic root enlargement: A multicenter propensity score–matched cohort analysisThe Journal of Thoracic and Cardiovascular SurgeryVol. 160Issue 4PreviewThe safety and efficacy of aortic root enlargement (ARE) at the time of aortic valve replacement (AVR) remains unknown. The objective of this multicenter study was to compare AVR with ARE to AVR for early and late mortality and secondary safety outcomes. Full-Text PDF Reply: Small aortic annulus: Can we dispel all the Hamletic doubts?The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 2PreviewThe great merit of Derrick Tam and the Toronto University Group1 was to turn the spotlight on aortic root enlargement (ARE) during aortic valve replacement, as demonstrated by the letter of De Martino and colleagues.2 The latter rightly pointed out the matter of surgical technique used for ARE. In 2014, the same group published the very long-term results of a small cohort of 53 patients undergoing aortic valve replacement (AVR), where enlargement of the aortic annulus was achieved using the Manouguian technique,3,4 extending so the aortotomy to separate the commissure between the left and noncoronary sinuses into the anterior mitral leaflet and closing the resulting defect with an adequately tailored patch of bovine pericardium; no case of severe patient–prosthesis mismatch (PPM) and no late aortic root aneurysm were recorded. Full-Text PDF REPLY FROM THE AUTHOR: Aortic root enlargement—more important than ever?The Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 2PreviewWe thank Martino and associates for their letter and interest in our study comparing early and late outcomes in those who underwent isolated aortic valve replacement (AVR) versus those who underwent AVR with concomitant aortic root enlargement (ARE) in 11 Ontario cardiac surgical centers from 2008 to 2017.1,2 There are several strategies to treat the small aortic root, including the use of stentless aortic valves, full root replacements, and more recently, sutureless valves as well as transcatheter valves. Full-Text PDF Reply: Fact or fiction: The benefit of aortic root enlargement during aortic valve replacementThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 2PreviewDe Martino and colleagues1 present an interesting perspective in their letter, suggesting that cardiac surgeons be trained in aortic root enlargement to prepare them for surgical conundrums they will invariably face in their career. Indeed, a cardiac surgeon's decision to perform root enlargement with aortic valve replacement (AVR) versus isolated AVR is not random, but rather based on tangible and imperceptible variables, including surgeon experience, baseline patient characteristics, and operative anatomy. Full-Text PDF Reply: Aortic root enlargement, again and againThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 2PreviewIn their Letter to the Editor published in this issue of the Journal, Martino and colleagues1 comment on a recently published article by Tam and colleagues2 on the subject of enlargement of the narrow aortic root (ARE) for implantation of a larger prosthesis than what the native annulus would otherwise permit. This article was accompanied by an invited commentary that I wrote.3 In the end, we all came out in favor of ARE; thus, there is not much to argue about in this letter, which was solicited by the Editor-in-Chief of the Journal. Full-Text PDF