Prosthesis-patient mismatch after surgical aortic valve replacement with aortic annular enlargement in small aortic annuli.

Objectives

Aortic annular enlargement (AAE) during surgical aortic valve replacement (SAVR) is performed to facilitate implantation of larger prostheses in patients with small aortic annuli and mitigate prosthesis-patient mismatch (PPM). However, the clinical impact of residual PPM after AAE remains uncertain.

Methods

All adult patients who underwent SAVR with AAE for small aortic annuli were retrospectively identified from a prospectively maintained institutional database (2011-2024). PPM was defined based on indexed effective orifice area thresholds derived from published reference tables. The primary outcome was all-cause mortality, and secondary outcomes included heart failure (HF) hospitalization, and longitudinal echocardiographic performance.

Results

A total of 169 patients were identified (age 68 years [61-73], 119 female [70.4%]). Median STS risk was 2% [1-4%], and preoperative mean gradient was 45.0 mmHg [36.8-57.2]. Overall median valve size after AAE was 23 mm (21-25), and PPM occurred in 25 patients (14.8%), including 24 (14.2%) with moderate and 1 (0.6%) with severe PPM. Early outcomes were comparable between PPM and no-PPM groups: postoperative stroke 0 (0%) vs. 3 (2.1%, p > 0.999), and 30-day mortality 1 (4.0%) vs. 5 (3.5%, p > 0.999). Over 4 years follow-up, survival (HR 0.94, 95%CI 0.40-2.21, p = 0.896) and freedom from HF hospitalization (HR 1.16, 95%CI 0.45-2.95, p = 0.760) were similar. Echocardiographic trends showed no differences in LVEF (p = 0.123) or mean gradient (p = 0.879) during follow-up.

Conclusions

In patients with small aortic annuli undergoing SAVR with annular enlargement, the incidence of PPM was low, and residual PPM did not adversely impact early postoperative outcomes, mid-term survival, or valve hemodynamics.