A Statewide Quality Initiative to Promote Aortic Annular Enlargement: Leading An Evolving Paradigm Shift
Recommended Citation
Magouliotis DE, Topcu AC, Estrada Mendoza RM, Dabir RR, Clark MJ, Pruitt AL, Pagani FD, and Yang B. A Statewide Quality Initiative to Promote Aortic Annular Enlargement: Leading An Evolving Paradigm Shift. Ann Thorac Surg 2025.
Document Type
Article
Publication Date
9-13-2025
Publication Title
The Annals of thoracic surgery
Abstract
BACKGROUND: Aortic annular enlargement (AAE) represents an important adjunct strategy during aortic valve replacement (AVR) enabling implantation of larger-size prosthesis to prevent patient-prosthesis mismatch. This study evaluates the results of a statewide quality improvement intervention (QII) to increase AAE adoption, including the novel "Y-incision" technique.
METHODS: Using The Society of Thoracic Surgeons database, we identified patients undergoing AVR with or without AAE from January 2018 to December 2023, excluding emergent and endocarditis cases. A QII was initiated in September 2021 and again, May 2023 featuring wet-lab training in AAE techniques. Patients were categorized into pre-QII (before September 2021) and post-QII groups. Primary endpoints were AVR+AAE incidence and median prosthesis size; secondary endpoints included 30-day mortality, transfusions, and morbidity. Sensitivity analyses were performed on isolated AVR+AAE cases.
RESULTS: Totally, 817 patients were included (pre-QII: 330; post-QII: 487) and 11.6% of the audited operative notes were reassigned to the QII "Y-incision" subgroup. Post-QII patients showed increased AVR+AAE incidence (7% vs. 19%; p< 0.001), with isolated AVR+AAE cases rising from 8% to 23% (p< 0.001). Median prosthesis size increased from 23 to 25 (p< 0.001). "Y-incision" adoption rose significantly (20% vs. 70%; p< 0.001), with more surgeons implementing the technique in the post-QII group (18 vs. 35). No significant differences were observed in secondary endpoints. Sensitivity analyses confirmed findings.
CONCLUSIONS: A pilot QII enhanced AAE adoption during AVR, leading to larger AV prosthesis size without a significant increase in morbidity/mortality. Future research should explore mid- and long-term benefits on patient outcomes, including quality of life and survival.
PubMed ID
40953788
ePublication
ePub ahead of print
