Long-term follow-up of patients undergoing aortic root enlargement for insertion of a larger prosthesis

To evaluate the long-term survival of patients undergoing aortic root enlargement (ARE) compared with those with small aortic root (SAR), exploring risk factors for late mortality as well as the influence of patient-prosthesis mismatch (PPM).

From January 1999 through December 2010, a total of 3724 patients underwent isolated or combined aortic valve replacement at our institution. From these, 239 (6.4%) had transannular ARE with a pericardial patch, to permit implantation of a larger prosthesis. This study population was compared with a control group of 767 patients (20.6%) who were considered to have SAR, as a prosthesis of size 21 or less was implanted. Mean age was comparable: 70.4 ± 12.5 vs 69.9 ± 9.6 years for ARE and SAR groups, respectively (P = 0.552). Female sex predominated in the control group (81.6 vs 88.0%; P = 0.011). Patients of the ARE group tended to have higher mean body surface area (1.59 ± 0.15 vs 1.57 ± 0.13 m(2); P = 0.061) and were less symptomatic (NYHA III-IV: 49.4 vs 57.9%; P = 0.021).

Implantation of bioprostheses was more frequent in the ARE group (76.2 vs 52.3%; P < 0.001), while concomitant procedures were more frequent in the SAR group (25.5 vs 32.2%; P = 0.050). Patients in the SAR group had higher moderate PPM (29.7 vs 50.1%; P < 0.001), but no patient was left with severe PPM. Hospital mortality was not statistically different between ARE and SAR groups (0.8 vs 0.5%; P = 0.632). The overall survival rate for ARE group patients at 5, 10 and 15 years was 82.7 ± 2.5, 64.8 ± 3.8 and 36.0 ± 7.5%, respectively, in comparison with 86.2 ± 1.3, 62.9 ± 2.3 and 38.4 ± 4.3% for the SAR group (P = 0.741). There was no significant difference in long-term survival of ARE patients compared with the age- and gender-matched general population (P = 0.794). Long-term survival was not affected by the presence of PPM. Increasing age, male sex, atrial fibrillation, LV end-systolic dimension, preoperative creatinine and NYHA class III-IV were significant predictors of late mortality.

ARE can be done safely, effectively reducing PPM. Although no difference was found in early and late mortality compared with the SAR group, long-term survival rates of ARE patients was comparable with that of the general population, unlike those of the SAR group.