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Editorial

Aortic Root Enlargement: Worth the Effort?

Division of Cardiothoracic Surgery, Lynn Heart Institute, Boca Raton Community Hospital, Boca Raton, Florida

^_* Address correspondence to Dr Kulik, Lynn Heart Institute, Boca Raton Community Hospital, 801 Meadows Rd, Ste 104, Boca Raton, FL 33486 (Email: alex_kulik@yahoo.com).

In patients with advanced aortic valve disease, the goals of aortic valve replacement (AVR) are to reduce pressure and volume overload on the left ventricle, relieve symptoms, and improve long-term survival. Ideally, transprosthetic pressure gradients after surgery should be minimal. Despite normally functioning prostheses, however, high pressure gradients are occasionally seen after surgery, particularly in patients who have received small-sized prosthetic valves. This results in persistent postoperative left ventricular outflow tract obstruction, a condition termed prosthesis–patient mismatch (PPM). First described by Rahimtoola [1] in 1978, PPM is described as an "effective prosthetic valve area, after insertion into the patient, that is less than that of a normal valve." Pibarot and Dumesnil [2] have since defined aortic PPM as a prosthetic valve effective orifice area (EOA) indexed to body surface area of less than 0.85 cm²/m².

Considerable controversy exists in literature regarding the significance of PPM and its impact on postoperative outcomes after valve replacement. Although some studies have suggested that there is no risk associated with PPM [3–5], others have demonstrated PPM to be a strong and independent risk factor for adverse events after AVR [2, 6–9]. Several groups have shown that PPM is associated with reduced early and late survival after AVR [2, 6, 7]. With residual postoperative gradients, PPM has also been linked to reduced left ventricular mass regression after surgery [8], as well as lower functional class and exercise tolerance [9]. Mismatch after mitral replacement has also been shown to have a detrimental impact on postoperative outcomes. Defined as an indexed EOA of less than 1.2 cm²/m², mitral PPM is associated with persistent pulmonary hypertension, congestive heart failure, and reduced survival after surgery [10].

The EOA of . . . [Full Text of this Article]

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