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J Thorac Cardiovasc Surg 2007;134:916-924
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Aortic root enlargement: What are the operative risks?

Jayesh Dhareshwar, MDa, Thoralf M. Sundt, III, MDa,*, Joseph A. Dearani, MDa, Hartzell V. Schaff, MDa, David J. Cook, MDb, Thomas A. Orszulak, MDa

a Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn
b Division of Cardiovascular Anesthesia, Mayo Clinic, Rochester, Minn.

Read at the Thirty-second Annual Meeting of the Western Thoracic Surgical Association, Sun Valley, Idaho, June 21-24, 2006.

Received for publication June 19, 2006; revisions received November 6, 2006; accepted for publication January 8, 2007.

* Address for reprints: Thoralf M. Sundt III, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905. (Email: sundt.thoralf{at}mayo.edu).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objective: Despite concern that small aortic valve prostheses can lead to prosthesis–patient mismatch with diminished left ventricular mass regression and poor long-term outcome after aortic valve replacement, there remains reluctance to perform aortic root enlargement procedures. We therefore examined the operative risks of aortic valve replacement with and without root enlargement.

Methods: We reviewed perioperative outcomes among patients undergoing aortic valve replacement at our institution between January 1993 and December 2001. Risk factors for operative death were evaluated by means of multivariable analysis.

Results: Of 2366 patients undergoing aortic valve replacement with (1173) or without (1193) concomitant procedures, 249 (10.5%) underwent posterior root enlargement. Patients undergoing complex root enlargement (Konno–Rastan procedures) were excluded. Patients undergoing aortic root enlargement were significantly younger, twice as often female, and more often undergoing a reoperation but were similar with respect to functional class. The mean valve implant size was less in the aortic root enlargement group (21.5 ± 1.6 vs 23.2 ± 2.3 mm, P < .0001). As expected, mean crossclamp time and bypass time were somewhat longer with root enlargement. Raw operative mortality was higher with aortic root enlargement (5.6% vs 2.9%, P = .0324); however, by means of multivariable analysis, advanced functional class (P = .0020; odds ratio, 1.87), preoperative congestive heart failure (P < .0001; odds ratio, 3.22), and smaller valve implant size (P = .012; odds ratio, 1.16), but not aortic root enlargement, were independent risk factors for operative death.

Conclusions: Aortic root enlargement 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 adequately sized valve prostheses.

Abbreviations and Acronyms ARE = aortic root enlargement; AVR = aortic valve replacement; iEOA = indexed effective orifice area; PPM = prosthesis–patient mismatch; STS = Society of Thoracic Surgeons


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
The surgical management of the small aortic root accordingly remains a relevant topic. It is intuitive that one would elect to replace a stenotic valve (or for that matter a regurgitant valve) with the least stenotic prosthesis. Therefore, it is not surprising that a number of studies have demonstrated superior left ventricular mass regression,1Go postoperative functional class and exercise tolerance,2Go and patient survival3Go when small valves are avoided. Furthermore, prosthesis–patient mismatch (PPM)4Go specifically has been shown by some investigators to adversely affect left ventricular mass regression5,6Go and both early and late survival.7-10Go

Other authors dispute the relevance of PPM in the current era, reporting little or no relationship between valve orifice size and outcome.11,12Go It has been further suggested that PPM is, in practice, quite uncommon.13Go These arguments are complicated by various definitions of PPM ranging from an indexed orifice area of less than 0.6 cm2/m2,13Go to less than 0.85 cm2/m2,11,12Go as well as dispute over the more appropriate measure of orifice area (geometric or effective).

Although some physicians continue to debate the clinical effect of aortic valve prosthesis size on outcome, interest in prosthetic hemodynamics persists. Indeed, superior hemodynamic performance is the very basis of many arguments in favor of the use of stentless xenografts and the Ross pulmonary autograft operation. Furthermore, hemodynamic improvements remain a common selling point among valve manufacturers, with each new-generation valve promising superior flow characteristics.

Regardless of academic argument, the practicing surgeon has a number of options available when confronted with the small aortic root and a circumstance in which he or she wishes to implant a valve larger than the annulus readily accepts. Among those options is posterior aortic root enlargement (ARE). Many surgeons are reluctant to perform ARE, however, out of concern that this adjunctive procedure will increase operative morbidity and mortality.14Go This approach, however, has been our institutional preference for management of the small annulus since Stenseth and colleagues15Go first introduced it as an approach to prevent tertiary orifice obstruction after implantation of the Starr–Edwards prosthesis. We find unappealing the more complex alternatives promulgated today using stentless xenografts, homografts, or autografts as full root replacements, a procedure associated with an almost 3-fold higher operative risk than simple aortic valve replacement (AVR) in the Society of Thoracic Surgeons (STS) database (http://www.sts.org).16Go We therefore reviewed our experience with ARE among patients undergoing AVR with or without concomitant procedures.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patient Population
After review and approval by the Mayo Clinic Rochester Institutional Review Board, we retrospectively reviewed the clinical records of 2366 consecutive adult patients undergoing AVR from January 1993 through December 2001. Of these, 249 (10.5%) underwent posterior root enlargement. Only those cases in which the operative note documented use of patch material to accomplish root enlargement, as opposed to its use to facilitate closure of a calcified or otherwise complicated aortotomy, were included. Patients undergoing Konno–Rastan procedures were excluded, as were patients undergoing concomitant mitral valve repair or replacement, aortic aneurysm repair, or composite aortic root reconstruction. Those undergoing concomitant coronary artery bypass grafting were included because they not only constituted a large fraction of both groups but also reflect the patient population in which the clinical decision to enlarge the annulus must be made in practice. Patients with other miscellaneous concomitant procedures, such as tricuspid valve repair and atrial septal defect closure, the effect of which on mortality was deemed negligible, were included. All clinical data were collected prospectively according to the guidelines and definitions of the STS database.

Surgical Technique
Operations were performed routinely under normothermic cardiopulmonary bypass with intermittent cold blood cardioplegia. There is no uniform policy in our unit with regard to minimum acceptable prosthesis size, and opinions vary among surgeons. If, however, the aortic annulus will not accept the valve size the surgeon believes to be appropriate for the given patient, it is our general preference to enlarge the annulus rather than implant a stentless xenograft valve or homograft.

There is considerable confusion in the literature regarding the techniques proposed by the eponymous descriptors Nicks’7Go and Manouguian’s17Go enlargement. Key figures from the original contributions are therefore reproduced in Figure 1. Our technique is similar to that outlined by Nicks and associates.7Go Our standard aortotomy for AVR is oblique, extending into the noncoronary sinus. If the aortic annulus will not accommodate the desired prosthesis, this aortotomy can be extended to but not beyond the annulus because widening the apex with pericardium permits implantation of a slightly larger valve by slightly tilting the prosthesis such that the prosthetic sewing ring rides above the native annulus and is secured to the patch itself.


Figure 1
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  		Figure 1. Original figures from articles published by Nicks and colleagues (A) and Manouguian and Seybold-Epting (B) first describing posterior root enlargement techniques. Figure 1A is reprinted from Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement. Thorax. 1970;25:339-46. Reproduced with permission from the BMJ Publishing Group. Figure 1B is reprinted from Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg. 1979;78:402-12. Reproduced with permission from Mosby.

 
A somewhat greater enlargement can be accomplished by extending the incision in the base of the noncoronary sinus beyond the aortic annulus onto the anterior mitral leaflet (Figure 2, A). Once across the annulus, the incision is directed posteriorly toward the center of the anterior leaflet of the mitral valve. A teardrop-shaped patch of autologous or bovine pericardium is sutured to the base of the incision with a 4-0 polypropylene suture, with the broader end of the patch at the apex. After completion of the suture line above the level of the divided annulus, the valve prosthesis is sutured in place in a supra-annular position with 2-0 pledgeted Ethibond (Ethicon, Somerville, NJ) mattress sutures. In the region of the patch, the sutures are passed full thickness from outside the patch to inside. The pericardial patch is then used to facilitate closure of the aortotomy (Figure 2, B).


Figure 2
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  		Figure 2. A: a, Nicks’ aortic root enlargement is accomplished by extending the aortotomy incision across the aortic annulus into the anterior leaflet of the mitral valve. b, Care must be taken to carry this incision posteriorly into the center of the anterior leaflet. c, The defect is closed with autologous or bovine pericardium. Figure 2B: d, Valve prosthesis is sutured in a supra-annular position. In the region of the patch, the sutures are passed full thickness from outside the patch to inside. e, The pericardial patch is then used to facilitate closure of the aortotomy.

 
As a cautionary technical note, there is potential for impingement of leaflet motion when a bileaflet mechanical prosthesis is implanted with this technique. Leaflet mobility must be conscientiously inspected. Rotation of the prosthesis to obtain optimal valve closure is not uncommon.

Statistical Analysis
Categoric factors were compared between groups by using the Fisher exact test, whereas continuous factors were compared by using Wilcoxon rank–sum tests. Univariate and multivariate risk factors for operative mortality were evaluated by using logistic regression analysis. The final multivariate model was constructed with a stepwise selection technique.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The clinical characteristics of the 2117 patients undergoing AVR without ARE (AVR group) and the 249 patients undergoing AVR with ARE (ARE group) are shown in Table 1. The mean age in the ARE group was somewhat lower than that of control subjects, and fewer had an ejection fraction of less than 35%. The latter might in part be due to the higher incidence of aortic regurgitation in the AVR group. Patients undergoing ARE were twice as often female, however, and they had more often undergone prior cardiac operations than had the control subjects. Both groups were similar with regard to their functional class and the presence of endocarditis.


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  		Table 1 Preoperative characteristics
 
As might be anticipated, both aortic crossclamp time and cardiopulmonary bypass time were modestly prolonged in the ARE group (Table 2). Although other concomitant procedures were more common in the AVR group, ARE appeared to add only approximately 10 minutes to the mean myocardial ischemic time. Mechanical valves were more often implanted in the ARE group, perhaps reflecting the somewhat younger age of those patients and the superior hemodynamic results obtained with these valves.


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  		Table 2 Operative details
 
As shown in Table 3, the incidence of postoperative stroke was similar in both groups, as was the incidence of reoperation for bleeding. Raw operative mortality, however, was higher in the ARE group (5.6% vs 2.9%, P = .0324). When only isolated AVR procedures were considered, the difference was slightly less and no longer statistically significant (4.5% vs 2.2%, P = .0953), although the trend remained.


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  		Table 3 Outcomes
 
Variables enlisted in the univariate and multivariate model for operative mortality are shown in Table 4. Crossclamp time and bypass time were not included because it was expected that these would be strongly associated with ARE. Univariate predictors of operative mortality included ARE procedure, as well as age, sex, body surface area, and valve implant size, in addition to New York Heart Association functional class and history of congestive heart failure. By means of multivariate analysis, however, only smaller valve implant size, preoperative functional class, and congestive heart failure remained significant. When both groups were matched for these significant variables, ARE was not a risk factor for death.


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  		Table 4 Predictors of operative mortality
 
Because the clinical decision regarding root enlargement is made among patients with small roots and prosthetic size itself was shown to be a risk factor in our study, we made an effort to match cohorts with comparative valve sizes. When a subgroup of patients with small valves were considered (Table 5, A), the difference in mortality rate was not statistically significant (7.1% vs 4.5%, P = .2139), although again the trend remained. Because performing an ARE permits implantation of a 1-size-larger valve, we also compared the group of patients with ARE and a valve size of less than 23 mm with the subset of patients in the AVR group having 1 valve size smaller (ie, <21 mm). The trend for a difference in mortality was smaller (6.0% vs 4.5%) and again not statistically significant (Table 5, B).


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  		Table 5A Valve size ≤21 mm
 

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  		Table 5B ARE ≤23 mm vs ARV ≤21 mm
 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Our data demonstrate that posterior ARE can be accomplished during AVR without significantly increasing operative risk. Additionally, our findings confirm small valve size as an independent risk factor for operative mortality. Taken together, these findings support the continued value of this approach as an option when a surgeon wishes to implant a larger prosthesis than the native aortic annulus would otherwise accept.

These findings are consonant with those of other authors. Sommers and David14Go observed a statistically insignificant trend toward a higher mortality rate among patients undergoing ARE (7.1% vs 3.5%); however, subsequent studies by both Castro and colleagues18Go and Kitamura and associates19Go reported mortality rates among patients undergoing ARE that were actually lower than those observed among patients undergoing isolated AVR (2.5% vs 4.3% and 3.6% vs 5.9%, respectively). In none of these studies did multivariate analysis identify ARE as a risk factor for operative death.

Our findings also confirm the observations of others that small valve size is itself a risk factor for operative death,8,20,21Go which might in part explain a higher observed mortality rate in the ARE group compared with the AVR group because the procedure is required among patients with a small annulus. The concept of PPM was formally introduced into the literature by Rahimtoola4Go in 1978. In theory, PPM exists to some degree whenever the effective orifice area of the prosthetic valve is less than that of the normal valve. In practice, this is the case, to a greater or lesser extent, with almost all prosthetic options. Indeed, this was the rationale put forward by Nicks and colleagues7Go in their original article on the subject of ARE. The disagreement on the subject concerns the clinical effect of PPM. Some authors argue that PPM rarely occurs,13Go and others argue that even if it is present, it is of no clinical significance.11,12Go Members of the opposing camp cite data indicating inferior left ventricular mass regression5,6Go and reduced long-term survival9,10,20Go among patients with PPM. Our data do not, however, address directly the issue of PPM, and accordingly, we cannot make statements based on our study results concerning the appropriate application of this technique. We can only document its low risk, particularly compared with that reported to the STS database for full root replacement.16Go

It should also be noted that arguments concerning PPM are complicated by disagreement over its definition. Perhaps not surprisingly, those who define PPM most stringently as an indexed effective orifice area (iEOA) of less than 0.60 cm2/m2,13Go report it to be a rare occurrence, whereas others who define it as an iEOA of less than 0.85 cm2/m2,11,12Go report little effect on late survival. Even more confusion is engendered by the various uses of effective orifice area and geometric orifice area for each of the very large number of valvular prostheses in clinical use. In an effort to account for this, a sophisticated analysis performed by investigators at the Cleveland Clinic using multivariable propensity scores and multivariable hazard function analyses with bootstrap resampling defined PPM in no less than 4 different manners, including manufacturers’ labeled valve size, manufacturers’ stated internal orifice area, indexed internal orifice area, and disease score as an expression of variant of internal orifice area from the expected value.12Go Regardless, it is intuitive that an operation performed to relieve valvular stenosis should leave the patient with the least possible residual obstruction to flow. It is also clear that transvalvular gradients increase exponentially as the iEOA decreases to less than 0.8 to 0.9 cm2/m2.22Go

Choice among the 3 common techniques of root enlargement can be dictated by individual surgeon experience, as well as complexity inherent to the procedure. The Konno–Rastan procedure23,24Go offers the greatest degree of root enlargement. It is a complex procedure, however, requiring creation of a ventricular septal defect and right ventriculotomy, with double-patch closure of both. This risks damage to the septal arteries, as well as the conduction system, and places the patient at risk of intercameral fistulae. The posterior root enlargement techniques described by Nicks and colleagues7Go and Manouguian and Seybold-Epting17Go are more straightforward technically, although arguments have been made concerning impedance to outflow imposed by angular distortion of the left ventricular outflow tract with overriding of the prosthesis on the anterior leaflet of the mitral valve. Choice between Nicks’ and Manouguian’s enlargement will likely be largely dictated by the surgeon’s preferred aortotomy, oblique or transverse, with the former enlargement representing an extension of the oblique and the latter an extension of the transverse approach (Figure 1). Both techniques as originally described cross the surgical annulus, although as commonly applied they might not.

Our study had significant limitations. Despite being the largest study of its kind in the literature, the number of patients in the study remains relatively small. Our failure to assign statistical significance to the observed difference in mortality might therefore be due to insufficient power. Furthermore, because the study includes patients operated on by a large number of surgeons without a rigidly defined institutional philosophy regarding acceptable prosthesis size, details of the decision-making process regarding ARE are vague. This does not, however, weaken the empiric observations reported. Finally, as noted above, our data address only one half of the risk–benefit equation determining the indications for ARE. With absent data concerning the effect of PPM on hemodynamic outcome, we cannot argue the place of ARE in the surgeon’s armamentarium nor justify its use in particular circumstances. Furthermore, we do not have hemodynamic measures of the effectiveness of posterior ARE in relieving the outflow gradient. Indeed, one could argue that the procedure as performed failed to provide sufficient annular enlargement because valve size remained a predictor of operative mortality. This might in part be due to inconsistency among surgeons with regard to extension of the enlargement across the true annulus. Nonetheless, our data do satisfactorily address the issue of incremental operative risk imposed by application of this approach.

We conclude that ARE using the Nicks technique can be accomplished with low operative risk, and accordingly, surgeons should not be reluctant to do so when they believe it is otherwise clinically indicated.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Gonzalez-Juanatey JR, Garcia-Acuna JM, Vega Fernandez M, Amaro Cendon A, Castelo Fuentes V, Garcia-Bengoechea JB, et al. Influence of the size of aortic valve prostheses on hemodynamics and change in left ventricular mass: implications for the surgical management of aortic stenosis. J Thorac Cardiovasc Surg 1996;112:273-280.[Abstract/Free Full Text]
  2. Hirooka K, Kawazoe K, Kosakai Y, Sasako Y, Eishi K, Kito Y, et al. Prediction of postoperative exercise tolerance after aortic valve replacement. Ann Thorac Surg 1994;58:1626-1630.[Abstract/Free Full Text]
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  9. Tasca G, Mhagna Z, Perotti S, Centurini PB, Sabatini T, Amaducci A, et al. Impact of prosthesis–patient mismatch on cardiac events and midterm mortality after aortic valve replacement in patients with pure aortic stenosis. Circulation 2006;113:570-576.[Abstract/Free Full Text]
  10. Mohty-Echahidi D, Malouf JF, Girard SE, Schaff HV, Grill DE, Enriquez-Sarano ME, et al. Impact of prosthesis–patient mismatch on long-term survival in patients with small St Jude Medical mechanical prostheses in the aortic position. Circulation 2006;113:420-426.[Abstract/Free Full Text]
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  13. Hanayama N, Christakis GT, Mallidi HR, Joyner CD, Fremes SE, Morgan CD, et al. Patient prosthesis mismatch is rare after aortic valve replacement: valve size may be irrelevant. Ann Thorac Surg 2002;73:1822-1829.[Abstract/Free Full Text]
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