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Ann Thorac Surg 2007;83:2044-2049
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Aortic Annular Enlargement During Aortic Valve Replacement: Improving Results With Time

Mark D. Peterson, MD, PhD, Michael A. Borger, MD, PhD, Christopher M. Feindel, MD*, Tirone E. David, MD

Division of Cardiac Surgery, Toronto General Hospital, Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Accepted for publication January 29, 2007.

* Address correspondence to Dr Feindel, Division of Cardiac Surgery, Toronto General Hospital, 200 Elizabeth St, Toronto, Ontario, M5G 2C4, Canada (Email: chris.feindel{at}uhn.on.ca).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Enlargement of the aortic annulus during aortic valve replacement permits insertion of a larger prosthetic valve. Previous reports suggest patch enlargement of the aortic annulus increases operative morbidity and mortality during aortic valve replacement. We compared outcomes for this procedure in a contemporary group of patients with those operated on during an earlier era, to determine whether aortic annular enlargement is still associated with worse outcomes.

Methods: We reviewed prospectively gathered data on all patients undergoing aortic valve replacement and aortic annular enlargement at our institution from 1995 to 2005 (n = 669). We compared patient outcomes from two consecutive time periods: 1995 through 2000 (n = 360) versus 2001 through 2005 (n = 309). Propensity matching adjusted for baseline differences in a secondary analysis.

Results: Operative mortality was significantly lower in the more recent surgical group (2.9% versus 7.2%; p = 0.013). The rates of perioperative myocardial infarction (1.9% versus 1.1%; p = 0.4), stroke (2.9% versus 3.3%; p = 0.8), and pacemaker implantation (9.1% versus 12.5%; p = 0.16) were similar for both groups (2001 through 2005 versus 1995 through 2000, respectively). The earlier group of patients had a higher prevalence of congestive heart failure, syncope, angina, New York Heart Association class III or IV symptoms, chronic obstructive pulmonary disease, mitral valve disease, and previous cardiac surgery. After adjusting for these baseline differences with propensity matching, the risk of perioperative death remained lower in the contemporary group (3% versus 7.5%; p = 0.04).

Conclusions: Enlargement of the aortic annulus in the modern era is a safe adjunct to aortic valve replacement, and should be considered in selected patients to avoid patient–prosthesis mismatch.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Advanced symptomatic aortic valve disease is effectively treated by aortic valve replacement (AVR), with the goal of relieving symptoms and increasing life expectancy. Most surgeons implant the largest possible prosthesis to minimize postoperative transvalvular gradients and promote left ventricular mass regression [1]. Conversely, implanting a valve that is too small relative to a patient’s body size results in patient–prosthesis mismatch (PPM) and may have multiple potential deleterious consequences [2–10].

Of the available surgical options that improve the effective orifice area (EOA) during AVR for patients with small aortic annuli relative to their body size, patch enlargement of the aortic annulus is relatively straightforward and allows implantation of a larger prosthetic valve. Surgeons may be reluctant to use this strategy because prior reports, including from our own institution, indicate a variable impact on perioperative mortality: some institutions report no increase in operative mortality compared with AVR alone [11, 12], whereas others demonstrate a nearly twofold increase in perioperative deaths [13]. In the current study, we compare the perioperative morbidity and mortality of enlargement of the aortic annulus during AVR from two consecutive time periods, to determine whether aortic annular patch enlargement in the current era is a safe adjunct to AVR.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
We reviewed prospectively collected data on all patients undergoing AVR with aortic annular enlargement at our institution from 1995 to 2005 (n = 669), including patients who had concomitant coronary artery bypass grafting or mitral or tricuspid valve surgery. Patients who had aortic annular enlargement during AVR between 1995 and 2000 (n = 360, 16% of total AVR population) were compared with a contemporary cohort of patients from 2001 to 2005 (n = 309, 21% of total AVR population). Our institutional research ethics board approved the study and waived the requirement for individual consent.

Perioperative Management
A median sternotomy was performed in all patients. After cardiopulmonary bypass was instituted, mild systemic hypothermia (32° to 34°C) was used in the majority of patients. Cold (8°C) cardioplegic solution was delivered antegrade directly into the coronary ostia to protect the myocardium in most patients. Retrograde cardioplegia was used in select cases.

Standard AVR was performed with either a bioprosthetic or a mechanical valve. The annulus was sized with standard prosthetic valve sizers. The decision to enlarge the annulus was made by the attending surgeon to maximize the EOA. We have previously described a technique for aortic annular enlargement [13, 14]. When the goal was to obtain an increase in aortic annular diameter of one valve size, we performed a Nicks single-patch procedure [15]. A Manouguian double-patch procedure was used for patients who required an increase in annular diameter of two valve sizes [16].

Once the aortic valve was excised and the annulus debrided, the aortotomy was extended into the noncoronary sinus and through the annulus. The incision was stopped 2 to 5 mm below the annulus for a Nick’s enlargement, and 10 to 15 mm below the annulus (onto the anterior leaflet of the mitral valve) for a Manouguian procedure. A teardrop-shaped patch of untreated autologous pericardium was sutured to the defect using a 4-0 polypropylene suture, starting at the nadir of the annular enlargement incision up to 2.0 cm above the plane of the annulus. A second patch of untreated autologous pericardium was used to close the defect in the roof of the left atrium for the Manouguian technique. The annulus was resized and the appropriate valve was chosen, corresponding to the sizer that passed comfortably through the annulus. Horizontal mattress pledgeted sutures were placed circumferentially around the native annulus with the pledgets on the ventricular side, using 2-0 nonabsorbable braided sutures. Sutures with large pledgets were used where the patch enlargement had been performed. The sutures were placed in the plane of the annulus with the pledgets resting on the outside of the patch.

Statistical Analysis
Statistical analysis was performed with SAS software (SAS version 8.1; SAS Institute, Cary, NC). Continuous variables are expressed as mean ± standard deviation and categorical variables as percentages throughout the manuscript. Continuous variables were compared between groups with unpaired Student’s t tests or the Kruskal-Wallis test. Categorical variables were analyzed with {chi}2 or Fisher’s exact tests. Backward stepwise logistic regression identified independent predictors of death during AVR and aortic annular enlargement. Propensity matching adjusted for baseline differences in a subgroup analysis, as previously described [17]. A two-tailed p value less than 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Table 1 illustrates the demographic differences in preoperative characteristics for patients who underwent aortic annular enlargement during AVR from 1995 to 2000 compared with 2001 to 2005. The earlier time group had a higher proportion of patients with congestive heart failure, New York Heart Association class III or IV symptoms, angina, syncope, chronic obstructive pulmonary disease, concomitant mitral valve disease, reoperation, and smaller body surface area. Because the clinical profile of patients differed significantly between the two groups, we used propensity matching to create equal sized groups with similar demographic profiles (n = 400, n = 200 per group). After propensity matching, patients in the two groups were similar for all preoperative variables, with the exception of a greater proportion of patients with left ventricular ejection fraction less than 0.40 in the more recent time group (Table 2).


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  		Table 1 Preoperative Characteristics of Patients Who Underwent Aortic Annular Enlargement During Aortic Valve Replacement Between 1995 and 2000 Versus 2001 and 2005 a
 

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  		Table 2 Preoperative Characteristics of Propensity-Matched Patients Who Underwent Aortic Annular Enlargement During Aortic Valve Replacement Between 1995 and 2000 Versus 2001 and 2005 a
 
Figure 1 compares the distribution of valve sizes implanted after aortic annular enlargement between the two study groups. Valves sized 21 to 25 were implanted in the majority of patients, with no difference in the distribution of valve sizes between the two groups (Fig 1; p = 0.07). After propensity matching, the mean valve size implanted was slightly greater for patients operated on between 2001 and 2005 (Fig 2; p = 0.04).


Figure 1
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  		Fig 1. Size of aortic prosthesis implanted after aortic annular enlargement from 1995 to 2000 (white bars) versus 2001 to 2005 (black bars).

 

Figure 2
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  		Fig 2. Size of aortic prosthesis implanted after aortic annular enlargement in propensity-matched patients from 1995 to 2000 (white bars) versus 2001 to 2005 (black bars).

 
Intraoperative variables are displayed in Tables 3 and 4. Go The duration of cardiopulmonary bypass and aortic cross-clamping were slightly longer for patients receiving annular enlargement during AVR between 2001 and 2005 (Table 3). There was a trend toward more mitral valve surgery in the earlier cohort of patients (p = 0.07), whereas patients in the contemporary group had more ascending aortic replacements (p = 0.01). Once patients were propensity matched for baseline demographic differences, intraoperative variables were similar between the two time groups (Table 4).


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  		Table 3 Intraoperative Characteristics of Patients Who Underwent Aortic Annular Enlargement During Aortic Valve Replacement Between 1995 and 2000 Versus 2001 and 2005 a
 

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  		Table 4 Intraoperative Characteristics of Propensity-Matched Patients Who Underwent Aortic Annular Enlargement During Aortic Valve Replacement Between 1995 and 2000 Versus 2001 and 2005 a
 
Early postoperative outcomes are displayed in Tables 5 and 6. Go Patients who underwent aortic annular enlargement and AVR between 2001 and 2005 had a significantly longer duration of postoperative ventilatory support and intensive care unit stay than the earlier time group, for both unmatched and propensity-matched patients (Tables 5 and 6). Postoperative morbidity was otherwise similar between the two groups.


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  		Table 5 Postoperative Outcomes of Patients Who Underwent Aortic Annular Enlargement During Aortic Valve Replacement Between 1995 and 2000 Versus 2001 and 2005 a
 

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  		Table 6 Postoperative Outcomes of Propensity-Matched Patients Who Underwent Aortic Annular Enlargement During Aortic Valve Replacement Between 1995 and 2000 Versus 2001 and 2005 a
 
Figure 3 illustrates the operative mortality for the two groups. Patients who underwent aortic annular enlargement between 2001 and 2005 had a significantly lower operative mortality than patients operated on before 2001 (2.9% versus 7.2%; p = 0.013). Similarly, the operative mortality remained lower in the later time group after propensity matching (3% versus 7.5%; p = 0.04; Fig 4). We also compared the operative mortality of patients who underwent aortic annular enlargement during AVR (n = 309) to all patients who underwent AVR (n = 1535), without annular enlargement, during the most recent time period (2001 through 2005). The mortality for patients without annular enlargement was similar to that of patients who had combined AVR and annular enlargement (3.3% versus 2.9%, respectively; p = 0.5). Furthermore, multivariable logistic regression on data from all patients who underwent AVR did not identify aortic annular enlargement as a predictor of operative mortality (p = 0.4).


Figure 3
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  		Fig 3. Perioperative mortality of patients who underwent aortic annular enlargement during aortic valve replacement from 1995 to 2000 (white bars) versus 2001 to 2005 (black bars).

 

Figure 4
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  		Fig 4. Perioperative mortality of propensity-matched patients who underwent aortic annular enlargement during aortic valve replacement from 1995 to 2000 (white bars) versus 2001 to 2005 (black bars).

 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
Aortic valve replacement for patients with advanced aortic valve disease reduces mortality, ameliorates exercise capacity, and promotes regression of left ventricular hypertrophy. To maximize the therapeutic benefit from AVR, an appropriately sized prosthesis should be implanted into the patient, as a prosthesis with a small EOA may result in persistence of high transvalvular pressure gradients [3, 5]. Rahimtoola [18] was the first to describe PPM based on the disparity between prosthesis and normal human valve area. The concept was extended by Dumesnil and Pibarot [19] to describe a prosthesis with an orifice that is too small relative to the patient’s body surface area. Although the clinical relevance of PPM has been fervently debated in the literature, with some studies unable to demonstrate a relationship between valve size and outcome [20, 21], a growing number of studies have associated PPM with increased early and late mortality, decreased exercise tolerance, and decreased left ventricular mass regression [2, 6–10, 22–25].

Patch enlargement of the aortic annulus may minimize the risk of PPM by allowing insertion of a prosthetic valve one to two sizes larger than with AVR alone. Other options for avoiding PPM in patients with a small aortic annulus include insertion of a homograft, autograft, or stentless bioprosthesis, as well as total aortic root replacement. However, such procedures must balance the potential benefit of implanting a larger valve against the possible increase in operative morbidity and mortality. Of the surgical options listed above, aortic annular patch enlargement may be the simplest and most reproducible technique. In the present study, our contemporary operative mortality for patch enlargement of the aortic annulus was 2.9%, despite the fact that more than half of the patients underwent concomitant procedures including coronary artery bypass grafting, mitral valve surgery, tricuspid valve surgery, and replacement of the ascending aorta. The low mortality rate suggests that aortic annular enlargement can be safely performed during AVR.

We have previously reported that the operative mortality rate for patch enlargement of the aortic annulus was 7.1%, double the operative mortality for AVR alone [13]. The reported rate was similar to the earlier cohort (1995 through 2000) detailed in the current study (operative mortality, 7.2%). It is tempting to speculate that the lower operative mortality observed in the contemporary group (2001 through 2005) may be related to the decreased incidence of preoperative risk factors such as congestive heart failure, concomitant mitral valve disease, or prior cardiac operation compared with the earlier group (1995 through 2000). We therefore performed propensity score matching to obtain a similar risk profile for the two groups of patients, with the exception of a higher risk of left ventricular ejection fraction less than 0.40 in the contemporary group (Table 2). After propensity matching, operative mortality was again lower in the contemporary cohort (3% versus 7.5% for 2001 through 2005 versus 1995 through 2000, respectively; p = 0.04).

What factors account for the lower mortality observed in the contemporary group? Our technique for patch enlargement did not change significantly during the present study, with the exception that some surgeons currently suture a second 5-0 polypropylene layer, starting at the base of the patch and running up both sides of the aorta, as a precaution against bleeding [14]. In the study reported by Sommers and David [13], surgeon inexperience with patch enlargement was associated with a higher mortality, although the individual surgeon was not identified as an independent predictor of death with aortic enlargement. Increased comfort and experience with this technique by more surgeons at our institution could have led to the observed lower operative mortality in the most recent group (2001 through 2005).

Other groups have reported similarly low perioperative mortality associated with aortic annular enlargement. Castro and colleagues [11] performed aortic root enlargement in 17% of patients undergoing AVR (n = 114) between 1995 and 2001, with a 30-day mortality of 0.9%. Selective use of this strategy added only 19 minutes of aortic cross-clamp time, but they avoided PPM in all but 3% of patients undergoing AVR. Similarly, Sakamoto and associates [12] performed either the Manouguian or the Nicks procedure in 18.8% of patients undergoing AVR (n = 24) with a resultant incidence of PPM of only 1.1%. These authors also reported equivalent 10-year actuarial survival for patients with and without annular enlargement. In addition, Okuyama and associates [26] performed the Manouguian root enlargement during double-valve replacement with a similar operative mortality and long-term survival compared with double-valve replacement alone.

Although our group and others have demonstrated that aortic annular enlargement can be performed safely in the current era, this technique should be judiciously used on selected patients most likely to derive maximal benefit. Pibarot and Dumesnil [5] have suggested a preoperative strategy, based on a patient’s body surface area and the published prosthetic valve EOAs, whereby a surgeon would optimally implant a valve with an indexed EOA of greater than 0.85 cm2/m2, because valves with smaller indexed EOAs produce significant pressure gradients both at rest and with exercise. Patient–prosthesis mismatch clearly represents a continuum [6, 8], therefore the threshold value for deciding when to enlarge the annulus to admit a larger valve must account for the clinical scenario and the expected benefit. For example, patients with reduced left ventricular function may be at higher risk of death after AVR with an inadequately sized prosthetic valve [6, 9, 22], therefore enlarging the root to avoid PPM, despite the added time and potential risk, would appear justified. Young active patients with relatively small aortic annuli are also more likely to derive greater improvements in their functional capacity because implanting valves with indexed EOAs less than 0.85 cm2/m2 has resulted in less symptomatic improvement after AVR [3, 4]. In contrast, aortic annular enlargement is probably not required in elderly patients who are physically inactive because the expected benefit would be small.

In summary, our contemporary results with patch enlargement of the aortic annulus support its use as a safe adjunct to AVR, and should be considered in selected patients to avoid PPM.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
We are indebted to Manjula Maganti for assistance with the statistical analysis.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

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