Aortic Root Enlargement in Patients With Small Aortic Annulus Undergoing Double Valve Replacement: A Retrospective Comparative Cohort Study

Background: Small aortic annulus (AA) is a big issue during aortic valve replacement (AVR), necessitating replacement of an undersized prosthetic valve especially with double valve replacement (DVR). Despite the fact that small aortic valve prostheses can lead to prosthesis-patient mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures, fearing morbidity and mortality. Objective: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus (<18 mm) undergoing double valve replacement. Methods: The study included 100 consecutive patients who underwent DVR for combined rheumatic aortic and mitral valve diseases, between January 2016 and September 2020. Only 50 patients had ARE with DVR. ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick's or Manouguian procedures. The estimated postoperative endpoints were mortality, effective orifice areas (EOA), mean aortic pressure gradient (PG), and valve-related complications. The shortest postoperative follow-up period was 6 months. Results: The study included 30 male and 70 female patients with mean age of 35 +/- 20 years, body surface area (BSA) of 1.7 +/- 0.3 m(2), aortic annulus diameter was 1.4 +/- 0.4 mm, aortic orifice area was 0.8 +/- 0.1 cm(2), and mean pressure gradient 85 +/- 2.5 mmHg. During the follow-up period, there was a mild to moderate paravalvular leak (1%) with 1% heart block and residual gradient on prosthetic aortic valve; this was all in DVR alone. Conclusion: Enlargement of the aortic root by Nick's or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.