Incremental Risk of Annular Enlargement: A Multi-Institutional Cohort Study

Abstract Background Annular enlargement (AE) is a critical technique to avoid patient-prosthesis mismatch and may help facilitate future valve-in-valve (ViV) transcatheter replacement. We hypothesized the addition of annular enlargement would increase risk of morbidity and mortality and that the number of annular enlargement procedures is increasing to accommodate future ViV procedures. Methods Patients undergoing aortic valve replacement ± coronary surgery (2012-2017) were extracted from a regional Society of Thoracic Surgeons database. Patients were stratified by annular enlargement and era, pre-ViV (2012-2014) versus ViV (2015-2017) for univariate analysis. Risk-adjusted outcomes were assessed by hierarchical regression modeling adjusting for predicted risk of mortality. Results Of 6,045 patients, the 300 (5.0%) who received an annular enlargement were younger and more commonly female. Patients receiving an annular enlargement had higher complication rates including operative mortality (4.7% versus 2.5%, p=0.024). After risk adjustment, AE was independently associated with increased mortality (OR 2.06, p=0.016) and major morbidity (OR 1.41, p=0.042)..The rate of enlargement increased from 3.9% pre-ViV to 6.3% ViV (p Conclusions Increasing utilization of AE coincides with a decline in patient prosthesis mismatch and may facilitate future ViV TAVR. However, AE was independently associated with increased morbidity and mortality. High variability in AE volume may be increasing risk and deserved further investigation.