Surgical treatment of valvular aortic stenosis in combination with a narrow aortic root. The site of posterior aortoplasty in adults. An overview of the need for this operation, its execution techniques and our experience. Literature review

Abstract

Aim: to describe the current state of the problem of surgical expansion of the aortic root during aortic valve replacement. Aortic valve replacement is a radical operation aimed at reducing the symptoms of chronic heart failure, reducing left ventricular overload, regressing its hypertrophy, and thereby increasing the quality and life expectancy of the patient. For the greatest success of the operation, the replacement should be made with the appropriate valve size suitable for the particular patient. Materials and methods. The latest literature data on the place of surgical expansion of the aortic root in the problem of treating aortic stenosis were studied. The own experience of these operations during the implantation of mechanical and biological prostheses in the aortic position in the practice of the cardiosurgical department of the Belgorod Regional Clinical Hospital is presented. Results. The study is devoted to the actual problem of choosing the right size of the prosthesis, the frequency of additional surgical procedures for its placement. Many studies have established an association between prosthesis-patient mismatch (PPM) and surgical outcome. The association of prosthesis-patient mismatch with long-term survival is inverse, although sometimes reported as ambiguous. We reviewed the literature and our experience with the surgical management of narrow aortic root situations to determine the incidence of PPM and the need for an additional surgical procedure of posterior aortoplasty to accommodate the appropriate size of the prosthesis. The results of modern meta-analyses, multicenter studies and limited series of operations presented in the literature are reviewed. The experience of the cardiosurgical department of the Belgorod Regional Clinical Hospital for the period 01.01.2015-30.04.2023 in aortic valve replacement with a small size of the aortic ring (17-20 mm) is presented. The study material consisted of 303 patients. As prosthesis-patient mismatch, we defined all cases of posterior aortoplasty with implantation of an appropriately sized aortic prosthesis. According to modern studies, the incidence of prosthesis-patient mismatch in aortic valve replacement without aortic root plasty is 11-33%. The frequency of posterior aortoplasty in adults is, according to different authors, 5-40%. Our experience has shown that the situation of PPM, which required aortic plasty, occurred in 14.8% of cases of implantation of stented biological prostheses, in 17.3% of cases of implantation of mechanical bicuspid prostheses. In general, on average, aortic plasty was performed in 15.8% of cases. Prosthetic-patient mismatch in aortic valve replacement occurs at a relatively constant rate. Posterior aortoplasty allows implanting the calculated size of the prosthesis and avoiding this problem. Conclusion. Surgery to patch the aortic root to accommodate an adequately sized prosthesis in the aortic position is required in 15-30% of patients with narrow aortic annulus. It allows you to get good hemodynamic results. The surgical risk of the operation is low.