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The following is a summary of “Surgeon Frequency of Aortic Root Enlargement and Long-term Survival in Medicare Beneficiaries Undergoing Surgical Aortic Valve Replacement” published in the March 2025 issue of American Journal of Cardiology by Eisenga et al.

Aortic root enlargement (ARE) is selectively performed during surgical aortic valve replacement (SAVR) to mitigate the risk of patient-prosthesis mismatch (PPM), yet its impact on long-term survival remains insufficiently characterized. This retrospective cohort study analyzed Medicare beneficiaries who underwent isolated SAVR with or without non-Konno ARE between 1999 and 2019. Procedural details were rigorously adjudicated using ICD and CPT codes, and overlap propensity score weighting was applied to adjust for potential confounders. Researchers compared restricted mean survival times (RMST) at 30 days and 20 years and stratified surgeons based on their frequency of ARE utilization to assess survival differences in both “as-treated” (SAVR vs. SAVR+ARE) and “surgeon-preference” (never-ARE vs. frequent-ARE surgeons) analyses. Among 214,266 beneficiaries undergoing isolated SAVR, 6,652 (3.1%) underwent SAVR+ARE. 

Over the study period, the utilization of ARE increased from 2.1% in 1999 to 6.4% in 2019 (Cochran-Armitage Z-statistic: 15.2). Of the 3,018 surgeons performing SAVR, 1,513 never performed ARE (treating 69,389 patients), 1,227 performed ARE in fewer than 10% of cases (treating 128,258 patients), and 278 performed ARE in at least 10% of cases (treating 16,619 patients). After risk adjustment, survival outcomes were significantly worse among patients undergoing SAVR+ARE compared to those receiving SAVR alone. At 30 days, RMST was lower in the SAVR+ARE group (28.73 [28.60–28.87] vs. 29.35 [29.26–29.45] days, p=0.013), and at 20 years, RMST remained lower (9.15 [8.96–9.35] vs. 9.49 [9.30–9.69] years, p=0.018). Similarly, patients treated by frequent-ARE surgeons had worse early risk-adjusted survival with no evidence of long-term benefit (30-day RMST: 29.19 [29.11–29.27] vs. 29.33 [29.25–29.40] days, p=0.013; 20-year RMST: 9.04 [8.90–9.18] vs. 9.13 [9.00–9.27] years, p=0.351). A landmark analysis of 1-year survivors showed no significant difference in long-term survival (p=0.456 in the “as-treated” analysis; p=0.943 in the “surgeon-preference” analysis). Even among surgeons with a high frequency of ARE utilization, SAVR+ARE was associated with higher 30-day mortality and a reduced 20-year RMST compared to SAVR alone. 

In conclusion, ARE was linked to increased early mortality and provided no long-term survival benefit, even when performed by experienced surgeons. These findings suggest that the routine use of ARE may not be justified in the broader SAVR population. Further investigations are warranted to evaluate the potential role of ARE in younger patients, those with small aortic annuli, and those at high risk for PPM to determine whether specific subgroups may derive meaningful benefit from this procedure.

Source: ajconline.org/article/S0002-9149(25)00142-0/abstract