Systematic Annulus Enlargement to Facilitate a Larger Prosthesis in Young Patients with Small Aortic Annuli Undergoing Surgical Aortic Valve Replacement

All articles of this category (opens in new window) Background: Despite advances in aortic valve prosthesis design, valve prostheses result in significantly smaller effective orifice areas (EOA) compared to the native aortic valve. This problem is extremely pertinent in young patients with small aortic annuli, who have a longer life expectancy and may experience patient prosthesis mismatch (PPM) and its consequences after surgical aortic valve replacement (SAVR). We present our initial experience with systematic annulus enlargement to facilitate a larger prosthesis in young patients with small annuli undergoing aortic valve replacement. Methods: From May 2022 to March 2025, 30 patients (24 females; age: 62 ± 10 years, Median STS score 3.8% [2.8–4.7]%, BSA was 1.75 ± 0.59 m 2 ) underwent SAVR. Mean CT-derived preoperative annulus area was 349 mm 2 ± 111 mm 2 . The aortic annulus enlargement was performed using either the Yang-incision ( n = 28 patients) or the Konno Rastan technique ( n = 2 patients). Additional concomitant procedures were performed in 18 patients (60%). In 18 patients, this was the first major cardiac operation; in 11 (37%) patients, at least the second, and in one patient, the fifth operation in their lifetime. Three patients were referred for redo surgery after significant PPM of their previous aortic valve prosthesis. Results: Mean CT-derived preoperative annulus area was 349 ± 111 mm 2 . Intraoperatively and without enlargement, a size of 19.2 ± 1.7 mm could have been implanted with an expected projected EOAi of 0.83 ± 0.16 cm 2 /m 2 and an expected early postoperative PPM rate of at least 50%. In all patients valve prosthesis at least two sizes larger was implanted after enlargement (prosthesis size 24.5 ± 1.8 mm; p < 0.001). Postoperative EOA and EOAi were 2.2 ± 0.5 cm 2 and 1.32 ± 0.34 cm 2 /m 2 , respectively ( p < 0.001 for both vs. anticipated without enlargement). Postoperative mean gradients were 9.4 [IQR: 6–11] mmHg. One patient died postoperatively due to multiple organ failure (observed mortality: 3.3%; expected: 3.8%, p = 0.9). Conclusion: Aortic annulus enlargement can be safely performed to upsize at least two valve prosthesis sizes and can effectively prevent PPM, especially in young patients with small aortic valve annuli. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany