Background: Surgical aortic root enlargement (ARE) during aortic valve replacement (AVR) allows for larger prosthesis implantation and may be an important adjunct to surgical AVR in the transcatheter valve-in-valve era. The incremental operative risk of adding ARE to AVR has not been established. We aimed to evaluate the early outcomes of patients undergoing AVR with or without ARE.

Methods: From January 1990 to August 2014, 7039 patients underwent AVR (AVR+ARE, n=1854; AVR, n=5185) at a single institution. Patients with aortic dissection and active endocarditis were excluded. Mean age was 65±14 years and 63% were male. Logistic regression and propensity score matching were used to adjust for unbalanced variables in group comparisons.

Results: Patients undergoing AVR+ARE were more likely to be female (46% versus 34%, P<0.001) and had higher rates of previous cardiac surgery (18% versus 12%, P<0.001), chronic obstructive pulmonary disease (5% versus 3%, P=0.004), urgent/emergent status (6% versus 4%, P=0.01), and worse New York Heart Association status (P<0.001). Most patients received bioprosthetic valves (AVR+ARE: 73.4% versus AVR: 73.3%, P=0.98) and also underwent concomitant cardiac procedures (AVR+ARE: 68% versus AVR: 67%, P=0.31). Mean prosthesis size implanted was slightly smaller in patients requiring AVR+ARE versus AVR (23.4±2.1 versus 24.1±2.3, P<0.001). In-hospital mortality was higher after AVR+ARE (4.3% versus 3.0%, P=0.008), although when the cohort was restricted to patients undergoing isolated aortic valve replacement with or without root enlargement, mortality was not statistically different (AVR+ARE: 1.7% versus AVR: 1.1%, P=0.29). After adjustment for baseline characteristics, AVR+ARE was not associated with an increased risk of in-hospital mortality when compared with AVR (odds ratio, 1.03; 95% confidence interval, 0.75–1.41; P=0.85). Furthermore, AVR+ARE was not associated with an increased risk of postoperative adverse events. Results were similar if propensity matching was used instead of multivariable adjustments for baseline characteristics.

Conclusions: In the largest analysis to date, ARE was not associated with increased risk of mortality or adverse events. Surgical ARE is a safe adjunct to AVR in the modern era.

背景：主动脉瓣置换术（AVR）期间的手术主动脉根部扩大术（ARE）允许更大的假体植入，并且可能是经导管瓣膜瓣置换时代手术AVR的重要辅助手段。尚未确定将ARE添加到AVR的增加的手术风险。我们旨在评估接受或不接受ARE的AVR患者的早期结局。

方法：从1990年1月至2014年8月，在单个机构中对7039例患者进行了AVR（AVR + ARE，n = 1854； AVR，n = 5185）。排除主动脉夹层和活动性心内膜炎的患者。平均年龄为65±14岁，其中63％为男性。在组比较中，使用逻辑回归和倾向得分匹配来调整不平衡变量。

结果：接受AVR + ARE治疗的患者中，女性更可能是女性（46％比34％，P <0.001），并且以前进行过心脏手术的比例更高（18％比12％，P <0.001），慢性阻塞性肺疾病（5） ％对3％，P = 0.004），紧急/紧急状态（6％对4％，P = 0.01）和纽约心脏协会状态较差（P <0.001）。大多数患者接受了生物人工瓣膜（AVR + ARE：73.4％，而AVR：73.3％，P = 0.98），并且还接受了心脏手术（AVR + ARE：68％，AVR：67％，P = 0.31）。与AVR相比，需要AVR + ARE的患者植入的平均假体尺寸稍小（23.4±2.1对24.1±2.3，P<0.001）。AVR + ARE术后院内死亡率较高（4.3％比3.0％，P = 0.008），尽管当队列仅限于接受单独主动脉瓣置换术并有或没有根扩大的患者时，死亡率无统计学差异（AVR + ARE ：1.7％，而AVR：1.1％，P = 0.29）。调整基线特征后，与AVR相比，AVR + ARE与院内死亡风险增加无关（比值比为1.03； 95％置信区间为0.75-1.41；P = 0.85）。此外，AVR + ARE与术后不良事件风险增加无关。如果使用倾向匹配代替基线特征的多变量调整，则结果相似。

结论：在迄今为止最大的分析中，ARE与死亡或不良事件的风险增加无关。手术ARE是现代AVR的安全附件。