Dealing with the small aortic annulus: are enlargement procedures obsolete?

In elderly patients, calcific aortic stenosis is often associated to a diminutive aortic annulus, a condition which may render surgical aortic valve replacement (AVR) more cumbersome. In fact, the main goal of AVR is not only to relieve left ventricular outflow obstruction but also to insert a prosthesis, ether biological or mechanical, of adequate size. As pointed out in the recent review on this subject by Vaidya et al. in the Journal of Cardiac Surgery,1 currently many different options are available, particularly with the aim of avoiding postoperative patient‐prosthesis mismatch (PPM). In the part dedicated to aortic root (AR) enlargement procedures they provide considerations which can create some confusion, particularly when they make no difference between AR and aortic annulus (AA) enlargement. Various techniques have been proposed for AA enlargement2; some of these, however, do not really enlarge the AA but only the AR without or little benefit in terms of increasing the size of the aortic prosthesis. Another statement which is not completely true is that experience with these techniques is limited.We have used in the past a simplified AA enlargement procedure with excellent early and late results, mainly employing a pericardial patch, either autologous or of bovine fixed in glutaraldehyde. 3 Particularly in a series of >50 patients we have reported a 2% operative mortality and stability of the repair up to 18 years.4 With the currently available new, high performance devices, such as stentless and sutureless bioprostheses, the need for AA enlargement procedures has been consistently reduced. However, we believe that these techniques should be taught to all young surgeons not just to increase their cultural background but as a still valid option in AVR.5,6 Not doing so would be a great mistake; AA enlargement helped us in the past to get out of trouble may times