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Head of Research Department, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 7, Kiel D-24105, Germany
(Email: lutter{at}kielheart.uni-kiel.de).
Patient prosthesis mismatch is undesirable and continues to be a controversial topic since the beginning of aortic valve replacement. The major issue with patient prosthesis mismatch is the effective orifice area: all valve prostheses except stentless bioprostheses had a significantly smaller effective orifice area than the normal native valve. Therefore, in many patients with prosthetic heart valves, left ventricular outflow obstruction improved from severe to moderate [1], but a pathologic transprosthetic pressure gradient remains. In the case of a small aortic root, the remaining pressure gradient can be dramatical.
Despite the variety of artificial heart valves, no ideal prosthesis for the small aortic root is currently available. Small mechanical valves have superior hemodynamics compared with tissue valves but are often contraindicated in older patients. Conventional stented valves are hemodynamically disadvantageous due to the higher transprosthetic gradients.
Until now, aortic root enlargement, followed by implantation of an aortic mechanical valve or stentless bioprosthesis, seems to be the best choice to establish a nonobstructive left ventricular outflow and is a good match with the native annulus and body surface area.
The aim of the study by Kulik and colleagues [2] was to describe the patient benefit after enlargement of the small aortic root during aortic valve replacement. In contrast to previous reports, the enlargement was completed in a short period of time without increased mortality compared with the aortic valve replacement group. Nevertheless, the combination of a calcified root, potential bleeding risks, an insignificant long-term benefit, and an increased cross-clamp time of 10 minutes may yet prove problematic for the recovery of elderly patients.
The combined procedure (aortic root enlargement plus aortic valve replacement) resulted in a lower transprosthetic gradient compared with a simple aortic valve replacement and this may aid in the recovery of myocardial function. There was no significant improvement in long-term results (p = 0.17) or freedom from chronic heart failure (p = 0.08). This may be explained by the mixed prostheses that were used, which is a well-known problem of retrospective studies. Nonetheless, this experience provides a solid basis for further prospective analyses.
These data represent positive evidence for enlargement of a small aortic root to avoid patient prothesis mismatch. A decreasing trend of chronic heart failure after transprosthetic gradient reduction due to aortic root enlargement has been shown. Aortic root enlargement should be performed more frequently in patients with a large body surface area and a small aortic root.
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