Aortic root enlargement: Is it still the best surgical tool to avoid patient‐prosthesis mismatch after aortic valve replacement?

Abstract

Avoidance of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR), particularly in younger and active patients, is mandatory to obtain appreciable clinical outcomes. 1,2 The risk of PPM can be predicted by simple and reproducible diagnostic methods useful to evaluate the size of the aortic annulus and the valve area. 3 Even a residual moderate PPM, defined as an indexed effective aortic orifice area <0.85 cm 2 /m 2 has been associated with reduced left ventricular mass regression and increased mortality in patients undergoing AVR. 4 Assessment of transvalvular gradient at rest by transthoracic echocardiography remains the standard diagnostic tool for evaluating patients after AVR, but its reliability is limited by the observation that the gradient increases considerably during physical exercise, 5 and this often happens in the younger population.Several surgical options are available to prevent PPM. In cases where a biological valve is chosen a stentless or a sutureless valve may be a good option in younger patients, 6 while a TAVI seems the ideal approach in the elderly. However, in this perspective, and as the only solution in patients receiving a mechanical valve, aortic root enlargement (ARE), first proposed by Nicks et al., 7 and later modified by Manouguian et al. 8 has shown to be a safe, reproducible and low-risk technique. For these patients, indeed, ARE represents the best technique available to reduce or overcome the risk of severe or moderate PPM, by facilitating the implant of a larger prosthesis. The most frequently used material to How to cite this article: Stefanelli G. Aortic root enlargement:Is it still the best surgical tool to avoid patient-prosthesis mismatch after aortic valve replacement?