title: Management of small aortic annulus in the era of sutureless valves: A comparative study among different biological options.
abstract: Aortic valve replacement (AVR) in patients with a small aortic annulus is a challenging problem. The objective of this study was to compare 4 surgical approaches in terms of hemodynamics and perioperative outcomes.
  
  
  
  A retrospective single-center study included 351 consecutive patients with a small aortic annulus (≤21 mm) who underwent aortic valve surgery between January 2007 and December 2014. Surgical techniques included standard AVR in 259 (74%) patients, aortic root enlargement in 20 (6%), implantation of a stentless bioprosthesis in 23 (6%), and sutureless AVR in 49 (13%).
  
  
  
  Three hundred and eleven (89%) patients were female. The mean Logistic EuroSCORE II varied significantly among the groups and ranged from 6.5% ± 5.4% in the standard AVR group to 9.2% ± 4.7% in the stentless group. Early mortality occurred in 26 (7%) patients. Patients in the stentless group had the lowest aortic valve mean gradients on predischarge transthoracic echocardiography (10.9 ± 6.2 mm Hg; P < .001). In the stented group, the Trifecta prosthesis displayed the lowest postoperative mean transaortic gradient (10.3 ± 3.6; P < .001) with no severe prosthesis-patient mismatch. Postoperative gradients of the sutureless group were comparable with stented prostheses.
  
  
  
  In our study, stentless AVR and Trifecta bioprostheses had the best hemodynamic outcomes. The Perceval sutureless prosthesis provides reasonable hemodynamic performance and is a safe alternative.
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Aly
authors.initials: A
authors.lastname: Ghoneim
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Ismail
authors.initials: I
authors.lastname: Bouhout
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Philippe
authors.initials: P
authors.lastname: Demers
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Amine
authors.initials: A
authors.lastname: Mazine
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Mary
authors.initials: M
authors.lastname: Francispillai
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Ismail
authors.initials: I
authors.lastname: El-Hamamsy
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Michel
authors.initials: M
authors.lastname: Carrier
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada.
authors.forename: Yoan
authors.initials: Y
authors.lastname: Lamarche
authors.affiliation: Department of Cardiovascular Surgery, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada. Electronic address: andre.denis.bouchard@gmail.com.
authors.forename: Denis
authors.initials: D
authors.lastname: Bouchard
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000033:anatomy & histology* / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery*; D001705:Bioprosthesis; D004452:Echocardiography; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: aortic annulus; aortic valve replacement; prothesis-patient mismatch; stentless prostheses; sutureless prostheses