Surgical treatment of valvular aortic stenosis in combination with a narrow aortic root. The site of posterior aortoplasty in adults. An overview of the need for this operation, its execution techniques and our experience. Literature review

Aim: to describe the current state of the problem of surgical expansion of the aortic root during aortic valve replacement. Aortic valve replacement is a radical operation aimed at reducing the symptoms of chronic heart failure, reducing left ventricular overload, regressing its hypertrophy, and thereby increasing the quality and life expectancy of the patient. For the greatest success of the operation, the replacement should be made with the appropriate valve size suitable for the particular patient. Materials and methods. The latest literature data on the place of surgical expansion of the aortic root in the problem of treating aortic stenosis were studied. The own experience of these operations during the implantation of mechanical and biological prostheses in the aortic position in the practice of the cardiosurgical department of the Belgorod Regional Clinical Hospital is presented. Results. The study is devoted to the actual problem of choosing the right size of the prosthesis, the frequency of additional surgical procedures for its placement. Many studies have established an association between prosthesis-patient mismatch (PPM) and surgical outcome. The association of prosthesis-patient mismatch with long-term survival is inverse, although sometimes reported as ambiguous. We reviewed the literature and our experience with the surgical management of narrow aortic root situations to determine the incidence of PPM and the need for an additional surgical procedure of posterior aortoplasty to accommodate the appropriate size of the prosthesis. The results of modern meta-analyses, multicenter studies and limited series of operations presented in the literature are reviewed. The experience of the cardiosurgical department of the Belgorod Regional Clinical Hospital for the period 01.01.2015-30.04.2023 in aortic valve replacement with a small size of the aortic ring (17-20 mm) is presented. The study material consisted of 303 patients. As prosthesis-patient mismatch, we defined all cases of posterior aortoplasty with implantation of an appropriately sized aortic prosthesis. According to modern studies, the incidence of prosthesis-patient mismatch in aortic valve replacement without aortic root plasty is 11-33%. The frequency of posterior aortoplasty in adults is, according to different authors, 5-40%. Our experience has shown that the situation of PPM, which required aortic plasty, occurred in 14.8% of cases of implantation of stented biological prostheses, in 17.3% of cases of implantation of mechanical bicuspid prostheses. In general, on average, aortic plasty was performed in 15.8% of cases. Prosthetic-patient mismatch in aortic valve replacement occurs at a relatively constant rate. Posterior aortoplasty allows implanting the calculated size of the prosthesis and avoiding this problem. Conclusion. Surgery to patch the aortic root to accommodate an adequately sized prosthesis in the aortic position is required in 15-30% of patients with narrow aortic annulus. It allows you to get good hemodynamic results. The surgical risk of the operation is low.

1. Von Segesser L.K. The development of open valve surgery. Thoracic and Cardiovascular Surgery. From the magin mountain to rocket science. European Association for Cardio-Thoracic Surgery. 2010:178-189.

2. Ross D.N. Homograft replacement of the aortic valve. Lancet. 1962;2(7254):487. DOI: 10.1016/s0140-6736(62)90345-8.

3. Ross D.N. Replacement of aortic and mitral valves with a pulmonary autograft. Lancet. 1967;2(7523):956-958. DOI: 10.1016/s0140-6736(67)90794-5.

4. Blasi S., Ravenni G., Celiento M., De Martino A., Milano A.D., Bortolotti U. Durability of the Mitroflow Pericardial Prosthesis: Influence of Patient-Prosthesis Mismatch and New Anticalcification Treatment. Thorac Cardiovasc Surg. 2020;68(2):131-140. DOI: 10.1055/s-0038-1667201

5. Antunes M.J. Reply: Aortic root enlargement, again and again. J Thorac Cardiovasc Surg. 2021;161(2):e158-e159. DOI: 10.1016/j.jtcvs.2020.10.143.

6. Belov Yu.V., Charchyan E.R., Katkov A.I., Salagaev G.I., Vinokurov I.A. Impact of prosthesis-patient mismatch on long-term results of aortic valve replacement. Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2016;9(2):46-51 (in Russ.). DOI: 10.17116/kardio20169246-51. EDN: VTOHML.

7. Treibel T.A., Badiani S., Lloyd G., Moon J.C. Multimodality Imaging Markers of Adverse Myocardial Remodeling in Aortic Stenosis. JACC Cardiovasc Imaging. 2019;12(8 Pt 1):1532-1548. DOI: 10.1016/j.jcmg.2019.02.034.

8. Chan J., Dimagli A., Fudulu D.P., Sinha S., Narayan P., Dong T., Angelini G.D. Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom. Front Cardiovasc Med. 2023;9:1077279. DOI: 10.3389/fcvm.2022.1077279.

9. Nishimura R.A., Otto C.M., Bonow R.O., Carabello B.A., Erwin J.P. 3rd, Fleisher L.A., Jneid H., Mack M.J., et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e1195. DOI: 10.1161/CIR.0000000000000503.

10. Martin E., Dagenais F., Voisine P., Dumont E., Charbonneau E., Baillot R., Kalavrouziotis D., Mohammadi S. Surgical aortic valve replacement outcomes in the transcatheter era. J Thorac Cardiovasc Surg. 2015;150(6):1582-1588. DOI: 10.1016/j.jtcvs.2015.08.077.

11. Silaschi M., Conradi L., Treede H., Reiter B., Schaefer U., Blankenberg S., Reichenspurner H. Trends in Surgical Aortic Valve Replacement in More Than 3,000 Consecutive Cases in the Era of Transcatheter Aortic Valve Implantations. Thorac Cardiovasc Surg. 2016;64(5):382-389. DOI: 10.1055/s-0035-1564615.

12. Chhatriwalla A.K., Allen K.B., Saxon J.T., Cohen D.J., Aggarwal S., Hart A.J., Baron S.J., Dvir D., et al. Bioprosthetic Valve Fracture Improves the Hemodynamic Results of Valve-in-Valve Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv. 2017;10(7):e005216. DOI: 10.1161/CIRCINTERVENTIONS.117.005216.

13. Dvir D., Webb J.G., Bleiziffer S., Pasic M., Waksman R., Kodali S., Barbanti M., Latib A., et al. Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. JAMA. 2014;312(2): 162-170. DOI: 10.1001/jama.2014.7246.

14. From the American Association of Neurological Surgeons (AANS), American Society of Neuroradiology (ASNR), Cardiovascular and Interventional Radiology Society of Europe (CIRSE), Canadian Interventional Radiology Association (CIRA), et al. Multisociety Consensus Quality Improvement Revised Consensus Statement for Endovascular Therapy of Acute Ischemic Stroke.Int J Stroke. 2018;13(6):612-632. DOI: 10.1177/1747493018778713.

15. Raschpichler M., de Waha S., Holzhey D., Schwarzer G., Flint N., Kaewkes D., Bräuchle P.T., Dvir D., et al. Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement for Failed Surgical Aortic Bioprostheses: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2022;11(24):e7965. DOI: 10.1161/JAHA.121.024848.

16. Pibarot P., Magne J., Leipsic J., Côté N., Blanke P., Thourani V.H., Hahn R. Imaging for Predicting and Assessing Prosthesis-Patient Mismatch After Aortic Valve Replacement. JACC Cardiovasc Imaging. 2019;12(1):149-162. DOI: 10.1016/j.jcmg.2018.10.020.

17. 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(3):402-412.

18. Rittenhouse E.A., Sauvage L.R., Stamm S.J., Mansfield P.B., Hall D.G., Herndon P.S. Radical enlargement of the aortic root and outflow tract to allow valve replacement. Ann Thorac Surg. 1979;27(4): 367-373. DOI: 10.1016/s0003-4975(10)63319-x.

19. Nicks R., Cartmill T., Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement. Thorax. 1970;25(3):339-346. DOI: 10.1136/thx.25.3.339.

20. Ivanov V.A., Evseyev E.P. Aortic valve replacement in adult patients with a narrow aortic root. Khirurgiya. Zhurnal im.N.I. Pirogova. 2005;(10):23-33 (in Russ.). EDN: YUQSSK.

21. Bokeriya L.A., Gazal B. "Mismatch prosthesis-patient" in patients with a prosthetic aortic valve. Annaly khirurgii. 2012;(2):5-9 (in Russ.). EDN: SCKHGL.

22. Medalion B., Blackstone E.H., Lytle B.W., White J., Arnold J.H., Cosgrove D.M. Aortic valve replacement: is valve size important? J Thorac Cardiovasc Surg. 2000;119(5):963-974. DOI: 10.1016/S0022-5223(00)70091-2.

23. Chen J., Lin Y., Kang B., Wang Z. Indexed effective orifice area is a significant predictor of higher mid- and long-term mortality rates following aortic valve replacement in patients with prosthesis-patient mismatch. Eur J Cardiothorac Surg. 2014;45(2):234-240. DOI: 10.1093/ejcts/ezt245.

24. Rocha R.V., Manlhiot C., Feindel C.M., Yau T.M., Mueller B., David T.E., Ouzounian M. Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement. Circulation. 2018;137(15):1585-1594. DOI: 10.1161/CIRCULATIONAHA.117.030525.

25. Freitas-Ferraz A.B., Tirado-Conte G., Dagenais F., Ruel M., Al-Atassi T., Dumont E., Mohammadi S., Bernier M., et al. Aortic Stenosis and Small Aortic Annulus. Circulation. 2019;139(23):2685-2702. DOI: 10.1161/CIRCULATIONAHA.118.038408.

26. Mehaffey J.H., Haywood N.S., Hawkins R.B., Kern J.A., Teman N.R., Kron I.L., Yarboro L.T., Ailawadi G. Need for Permanent Pacemaker After Surgical Aortic Valve Replacement Reduces Long-Term Survival. Ann Thorac Surg. 2018;106(2):460-465. DOI: 10.1016/j.athoracsur.2018.02.041.

27. Salmasi M.Y., Theodoulou I., Iyer P., Al-Zubaidy M., Naqvi D., Snober M., Oo A., Athanasiou T.Comparing outcomes between valve-sparing root replacement and the Bentall procedure in proximal aortic aneurysms: systematic review and meta-analysis.Interact Cardiovasc Thorac Surg. 2019;29(6):911-922. DOI: 10.1093/icvts/ivz211.

28. Yang B., Patel H.J., Sorek C., Hornsby W.E., Wu X., Ward S., Thomas M., Driscoll A., et al. Sixteen-Year Experience of David and Bentall Procedures in Acute Type A Aortic Dissection. Ann Thorac Surg. 2018;105(3):779-784. DOI: 10.1016/j.athoracsur.2017.09.029.

29. Tully P.J., Aty W., Rice G.D., Bennetts J.S., Knight J.L., Baker R.A. Aortic valve prosthesis-patient mismatch and long-term outcomes: 19-year single-center experience. Ann Thorac Surg. 2013;96(3):844-850. DOI: 10.1016/j.athoracsur.2013.04.075.

30. Dayan V., Vignolo G., Soca G., Paganini J.J., Brusich D., Pibarot P. Predictors and Outcomes of Prosthesis-Patient Mismatch After Aortic Valve Replacement. JACC Cardiovasc Imaging. 2016;9(8): 924-933. DOI: 10.1016/j.jcmg.2015.10.026.

31. Beckmann E., Martens A., Alhadi F., Hoeffler K., Umminger J., Kaufeld T., Sarikouch S., Koigeldiev N., et al. Aortic valve replacement with sutureless prosthesis: better than root enlargement to avoid patient-prosthesis mismatch? Interact Cardiovasc Thorac Surg. 2016;22(6):744-749. DOI: 10.1093/icvts/ivw041.

32. Fallon J.M., DeSimone J.P., Brennan J.M., O'Brien S., Thibault D.P., DiScipio A.W., Pibarot P., Jacobs J.P., et al. The Incidence and Consequence of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement. Ann Thorac Surg. 2018;106(1):14-22. DOI: 10.1016/j.athoracsur.2018.01.090.

33. Iqbal A., Panicker V.T., Karunakaran J. Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients. Indian J Thorac Cardiovasc Surg. 2019;35(1):6-14. DOI: 10.1007/s12055-018-0706-3.

34. Aitaliyev S., Rumbinaitė E., Mėlinytė-Ankudavičė K., Nekrošius R, Keturakis V, Benetis R. Early outcomes of patient-prosthesis mismatch following aortic valve replacement. Perfusion. 2022;37(7):692-699. DOI: 10.1177/02676591211023286.

35. Bahlmann E., Cramariuc D., Minners J., Lønnebakken M.T., Ray S., Gohlke-Baerwolf C., Nienaber C.A., Jander N., Seifert R., et al. Small aortic root in aortic valve stenosis: clinical characteristics and prognostic implications. Eur Heart J Cardiovasc Imaging. 2017;18(4):404-412. DOI: 10.1093/ehjci/jew159.

36. De Martino A., Milano AD, Bortolotti U. Facing the small aortic root in aortic valve replacement: Enlarge or not enlarge? J Thorac Cardiovasc Surg. 2021;161(2):157-158. DOI: 10.1016/j.jtcvs.2020.09.136.

37. Yousef S., Brown J.A., Serna-Gallegos D., Navid F., Warraich N., Yoon P., Kaczorowski D., Bonatti J., et al. Impact of Aortic Root Enlargement on Patients Undergoing Aortic Valve Replacement. Ann Thorac Surg. 2023;115(2):396-402. DOI: 10.1016/j.athoracsur.2022.05.052.

38. Sá M.P.B.O., Zhigalov K., Cavalcanti L.R.P., Escorel Neto A.C., Rayol S.C., Weymann A., Ruhparwar A., Lima R.C. Impact of Aortic Annulus Enlargement on the Outcomes of Aortic Valve Replacement: A Meta-analysis. Semin Thorac Cardiovasc Surg. 2021;33(2):316-325. DOI: 10.1053/j.semtcvs.2020.06.046.

39. Yu W., Tam D.Y., Rocha R.V., Makhdoum A., Ouzounian M., Fremes S.E. Aortic Root Enlargement Is Safe and Reduces the Incidence of Patient-Prosthesis Mismatch: A Meta-analysis of Early and Late Outcomes. Can J Cardiol. 2019;35(6):782-790. DOI: 10.1016/j.cjca.2019.02.004.

40. Tam D.Y., Dharma C., Rocha R.V., Ouzounian M., Wijeysundera H.C., Austin P.C., Fremes S.E. Early and late outcomes following aortic root enlargement: A multicenter propensity score-matched cohort analysis. J Thorac Cardiovasc Surg. 2020;160(4): 908-919.e15. DOI: 10.1016/j.jtcvs.2019.09.062.

41. Goor D., Lillehei C.W., Edwards J.E. The "sigmoid septum". Variation in the contour of the left ventricular outlet. Am J Roentgenol Radium Ther Nucl Med. 1969;107(2):366-376. DOI:10.2214/ajr.107.2.366.

42. Blank R.H., Pupello D.F., Bessone L.N., Harrison E.E., Sbar S. Method of managing the small aortic annulus during valve replacement. Ann Thorac Surg. 1976;22(4):356-361. DOI: 10.1016/s0003-4975(10)64967-3.

43. Bortolotti U., Mossuto E., Maraglino G., Sturaro M., Milano A., Livi U., Stellin G., Mazzucco A. Annular enlargement during aortic valve replacement: preliminary results with a simplified technique. J Card Surg. 1992;7(3):235-239. DOI: 10.1111/j.1540-8191.1992.tb00807.x.

44. Nuñez L., Aguado M.G., Pinto A.G., Larrea J.L. Enlargement of the aortic annulus by resecting the commissure between the left and noncoronary cusps. Tex Heart Inst J. 1983;10(3):301-303.

45. Popov V.V. Posterior aortoplasty for narrow aortic root: a new solution to the problem. Zaporozhskiy meditsinskiy zhurnal. 2011;13(6):41-42 (in Russ.)

46. Kinsley R.H. The narrow aortic annulus. A technique for inserting a larger prosthesis. Am Heart J. 1977;93(6):759-761. DOI: 10.1016/s0002-8703(77)80072-0.

47. Sazonenkov M.A., Ismatov Kh.Kh., Tatarintsev A.M., Moskalev A.S., Pyatakov S.N. Echocardiographic calculations in definition of reasonable frequency of posterior aortoplasty during implantation of stented bioprosthesis neo-cor "Uni-Line"-21 in aortic position. Diagnosticheskaya i interventsionnaya radiologiya. 2021;15(4):18-26 (in Russ.). DOI: 10.25512/DIR.2021.15.4.01. EDN: RSJJIE.

48. Sazonenkov M.A., Skopin I.I., Ismatov K.H., Tatarintsev A.M., Moskalev A.S. Patch enlargement of the aortic root with the incision in right muscular trigone of left ventricle outflow tract. Acta Scientific Cardiovascular System. 2022;1(4):11-15.

49. Konno S., Imai Y., Iida Y., Nakajima M., Tatsuno K. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring. J Thorac Cardiovasc Surg. 1975;70(5):909-917.

50. Symbas P.N., Ware R.E., Hatcher C.R., Temesy-Armos P.N. An operation for relief of severe left ventricular outflow tract obstruction. J Thorac Cardiovasc Surg. 1976;71(2):245-249.

51. Jones E.L., Craver J.M., Morris D.C., King S.B. 3rd, Douglas J.S. Jr, Franch R.H., Hatcher C.R. Jr, Morgan E.A. Hemodynamic and clinical evaluation of the Hancock xenograft bioprosthesis of aortic valve replacement (with emphasis on management of the small aortic root). J Thorac Cardiovasc Surg. 1978;75(2):300-308.

52. Yamaguchi M., Ohashi H., Imai M., Oshima Y., Hosokawa Y. Bilateral enlargement of the aortic valve ring for valve replacement in children. New operative technique. J Thorac Cardiovasc Surg. 1991;102(2): 202-206.

53. Otaki M., Oku H., Nakamoto S., Kitayama H., Ueda M., Matsumoto T. Two-drectional aortic annular enlargement for aortic valve replacement in the small aortic annulus. Ann Thorac Surg. 1997;63:261-263. DOI: 10.1016/s0003-4975(96)01086-7