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Aortic Root Enlargement vs Small Valves in Small Patients: What are the Operative Risks?
J. Dhareshwar, T. M. Sundt, J. A. Dearani, H. V. Schaff, D. J. Cook, T. A. Orszulak. Mayo Clinic, Rochester, MN,
BACKGROUND:
Despite diminished left ventricular mass regression and poor long-term outcome in the presence of patient-prosthesis mismatch, there remains reluctance to perform aortic root enlargement (ARE). We therefore examined the operative risks of aortic valve replacement (AVR) with and without ARE.
METHODS:
We reviewed the operative mortality of patients undergoing AVR between January 1993 and December 2001. Risk factors for operative death were evaluated by multivariable analysis.
RESULTS:
Of 2381 patients undergoing AVR with (1161) or without (1220) concomitant procedures, 264 (11%) underwent ARE excluding Konno procedures. Patients undergoing ARE were slightly younger, were twice as often female, and more often reoperative, but were similar with respect to functional class. The mean valve implant size was less in the ARE group (21.5 ± 1.7 vs. 23.2 ± 2.3 mm, p<0.0001). As expected mean cross clamp time and bypass time were somewhat prolonged for ARE. Operative mortality was higher for ARE (5.68% vs. 2.88%, p=0.02), however risk factors by multivariable analysis were poor NYHA functional class (p=0.0011, odds ratio 1.93) and smaller valve implant size (p=0.018, odds ratio 1.13). ARE was not an independent risk factor for operative death.
CONCLUSIONS:
ARE itself does not increase operative risk, although it is most often required among high-risk patients. Surgeons should not be reluctant to enlarge the aortic root to permit implantation of an adequate size valve prosthesis.
Table | AVR
N= 2117 | ARE
N= 264 | P value | | Age (years) | 70.1 ± 12.2 | 63.8 ±19.7 | 0.001 | | Female (%) | 33.49 | 70.83 | <0.0001 | | NYHA 3 or 4 (%) | 73.35 | 81.3 | 0.14 | | Reoperation (%) | 5.57 | 31.44 | <0.0001 | | Cross clamp time (min) | 64 ± 26.1 | 77.6 ± 31.7 | <0.0001 | | Bypass time (min) | 93.6 ± 40.5 | 119.2 ± 54.7 | p<0.0001 | | Operative mortality (%) | 2.88 | 5.68 | 0.02 |
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