Prosthesis–Patient Mismatch and Aortic Root Enlargement: Indications, Techniques and Outcomes

Abstract

Prosthesis–patient mismatch (PPM) is defined as implanting a prosthetic that is insufficiently sized for the patient receiving it. PPM leads to high residual transvalvular gradients post-aortic valve replacement and consequently results in left ventricular dysfunction, morbidity and mortality in both the short and long term. Younger patients and patients with poor preoperative left ventricular function are more vulnerable to increased mortality secondary to PPM. There is debate over the measurement of valvular effective orifice area (EOA) and variation exists in how manufacturers report the EOA. The most reliable technique is using in vivo echocardiographic measurements to create tables of predicted EOAs for different valve sizes. PPM can be prevented surgically in patients at risk through aortic root enlargement (ARE). Established techniques include the posterior enlargement through Nicks and Manouguian procedures, and aortico-ventriculoplasty with the Konno–Rastan procedure, which allows for a greater enlargement but carries increased surgical risk. A contemporary development is the Yang procedure, which uses a Y-shaped incision created through the non- and left-coronary cusp commissure, undermining the nadirs of the non- and left-coronary cusps. Early results are promising and demonstrate an ability to safely increase the aortic root by up to two to three sizes. Aortic root enlargement thus remains a valuable and safe tool in addressing PPM, and should be considered during surgical planning.

Incidence, Implications, and Treatment of Patients With Severe Aortic Stenosis and Small Aortic Annulus

“…Surgical options to avoid PPM include stentless and sutureless valve implantation, aortic root enlargement, and aortic root replacement. 8 Aortic root enlargement is generally underused, partly because of concerns with the longer bypass time, the risks for bleeding and mitral regurgitation, and an increase in associated mortality in some studies. 9 Recent trends towards increased use with fewer complications are encouraging.…”

“…Strategies that avoid even smaller prostheses or could result in obstruction of the coronary arteries at the time of future intervention should be considered carefully whether TAVR or SAVR is the chosen initial therapy. [5][6][7][8] The decision for TAVR versus SAVR is complex and requires a heart team approach as well as shared patient decision-making. In the patient with SAA, additional considerations should include the availability and experience of surgeons with aortic root enlargement techniques, the availability and experience of the heart team with multiple TAVR platforms, and the increasing evidence base on comparative outcomes.…”