eComment: Aortic-root enlargement procedures: an invaluable surgical technique Free

We read with great interest the paper by Beckman et al. who evaluated if it is better to implant sutureless prosthesis for aortic valve replacement than applying aortic root enlargement procedures for avoiding patient-prosthesis mismatch (PPM) in patients with a small aortic annulus. The authors found that the 30-day mortality and survival rates were comparable in the two groups. The indexed effective orifice area (EOA) was only slightly lower and the incidence of severe PPM was not significantly higher in the sutureless valve patients so they concluded that sutureless valve implantation was an alternative to conventional aortic root enlargement to treat a small aortic annulus and avoid PPM [1].

We would like to add some thoughts about the surgical techniques that are used for enlargement of the small aortic annulus. When the goal is to obtain an increase in aortic annular diameter of one valve size, a Nicks single-patch procedure is performed. A Manougian double-patch procedure is used for patients who require an increase in annular diameter of two-valve sizes [2]. Peterson et al. showed that the mortality for patients without annular enlargement was similar to that of patients who had combined AVR and annular enlargement (3.3% versus 2.9%, respectively). Aortic annular enlargement was not identified as a predictor or operative mortality [2].

Castro et al. performed aortic root enlargement in 17% of patients undergoing aortic valve replacement (AVR) and found that 30-day mortality was 0.9%. The selective use of this strategy added only 19 minutes of aortic cross-clamp time, but they avoided PPM in all but 3% of patients undergoing AVR [3].

Losenno et al. in their comparative analysis of surgical techniques of aortic root enlargement (ARE) found that ARE procedures appeared equally efficacious in both small and larger aortic roots. All four techniques increased the annular diameter, but only the Manougian, modified Bentall and aortoventriculoplasty procedures allowed for the implantation of a larger prosthetic valve. The Nicks procedure did not allow for the implantation of a larger prosthesis.

Surgeon preference and patient factors might help in selecting the most appropriate ARE technique, as the Manougian and the modified Bentall procedures achieved similar increases in valve size [4]. Dhareshwar et al. found that aortic root enlargement itself did not increase operative risk, although it was most often required among high-risk patients [5]. Finally, surgeons should not be reluctant to perform aortic annular patch enlargement in order to implant adequately sized valve prostheses.

Conflict of interest: none declared.

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