Background: Although aortic valve replacement (AVR) has been the standard of treatment for severe aortic stenosis, a small aortic annulus (SAA) poses significant challenges. Improvements in valve designs and evolution in surgical techniques have led to improved outcomes, however, the ideal prosthetic valve remains elusive.Methods: We performed a comprehensive literature review to discuss the surgical management of aortic stenosis, with a special focus on patients with SAA.Results: Stentless valves and root replacement techniques have been shown to overcome the hemodynamic challenges associated with conventional stented bioprostheses, but are technically challenging and require longer cross-clamp times. Sutureless and rapid deployment valves mitigate the long operative time while maintaining the hemodynamic advantages. The use of transcatheter AVR has emerged as another reasonable alternative and has shown promise among patients with SAA, however, long-term outcomes are awaited.
Conclusion:There is no consensus regarding the type of valve prosthesis or replacement technique among patients with SAA. Consideration of patient comorbidities and valvular anatomy is paramount in planning the optimal strategy for AVR. Further long-term clinical trials are necessary to assess outcomes and achieve progress toward the development of the ideal prosthesis. K E Y W O R D S aorta and great vessels, clinical review, valve repair/replacement 1 | INTRODUCTION Valvular aortic stenosis (AS) is a disease characterized by leaflet thickening and calcification. Left untreated, it progresses from early sclerotic lesions to left ventricular outflow obstruction, resulting in reduced cardiac output, decreased exercise tolerance, heart failure, and death. 1 Valvular anatomy, hemodynamics, symptoms, as well as effects on left ventricular function, determine the severity of disease (Table 1).
| METHODSA search was conducted on PubMed and results were reviewed for articles published up until April 30, 2020. Search terms included "aortic stenosis," "aortic valve replacement," "small aortic annulus," "aortic valve disease," and "cardiac surgery," or any combination thereof. All article types including original fulllength articles, meta-analyses, prior reviews, and case series were included.