Aortic Root Enlargement Is Safe and Reduces the Incidence of Patient-Prosthesis Mismatch: A Meta-analysis of Early and Late Outcomes

Abstract

BackgroundAortic root enlargement (ARE) may be an important adjunct to aortic valve replacement (AVR) to prevent patient-prosthesis mismatch and facilitate future valve-in-valve transcatheter AVR (TAVR). However, the early safety and late benefits of adding surgical ARE to AVR remain controversial. MethodsMEDLINE and EMBASE were searched from 1946 to 2018 for articles comparing patients undergoing AVR+ARE with those undergoing AVR alone. A random-effects meta-analysis was performed to compare early and late clinical outcomes. ResultsA total of 2570 AVR+ARE and 5,991 AVR patients were included from 9 observational studies. There was no difference in early mortality (relative risk [RR] 1.21; 95% confidence interval [CI], 0.94-1.54; P = 0.13). Both cardiopulmonary bypass (mean difference [MD] 20 minutes; 95% CI, 15-25; P < 0.01) and aortic cross-clamp time (MD 14 minutes; 95% CI, 11-17, P < 0.01) were higher following AVR+ARE. There was no difference in the risk of permanent pacemaker implantation (RR 1.02; 95% CI, 0.83-1.25; P = 0.86), reoperation for bleeding (RR 1.05; 95% CI, 0.84-1.32; P = 0.64), or stroke (RR 0.93; 95% CI, 0.68-1.27; P = 0.65). The risk of moderate (indexed effective orifice area [iEOA] < 0.85 cm2/m2) and severe (iEOA < 0.65 cm2/m2) patient-prosthesis mismatch (PPM) was lower with AVR+ARE (RR 0.65; 95% CI, 0.51-0.83; P < 0.01) and RR 0.36; 95% CI, 0.16-0.82; P = 0.01, respectively). There was no difference in late mortality (incidence rate ratio [IRR] 1.05; 95% CI, 0.87-1.27; P = 0.59) at mean 7.8-year follow-up in 5 studies. ConclusionsSurgical ARE is a safe adjunct to AVR in selected patients that does not increase early adverse events and results in less patient-prosthesis mismatch. This strategy allows for a larger valve size at the time of implantation, an important consideration for potential future valve-in-valve procedures in the era of TAVR.