Long-Term Outcomes of Replica-Based Upsizing for Epic Supra Aortic Bioprosthesis

Different techniques allow implantation of biological aortic valve prostheses larger than associated with classic annulus sizing. We described a replica-based technique (upsizing) before that utilizes the patient's root anatomy. We here evaluate the safety and efficacy of upsizing compared with standard sizing using the Epic Supra bioprosthesis.We assessed 958 patients undergoing aortic valve replacement with the Epic Supra bioprosthesis between 2010 and 2023. Upsizing was defined as implantation of a prosthesis larger than the measured annular size without enlarging the annulus. We assessed hemodynamic and standard outcome parameters. Mean follow-up was 44.5 ± 31.2 months. Propensity score matching was used to adjust for baseline differences.Patient anatomy allowed upsizing in 62% of patients. Demographics and outcomes (perioperative mortality, reoperation, bleeding, and pacemaker implantation) were comparable between the matched groups. Immediate postoperative and long-term pressure gradients were consistently and significantly lower in the upsizing groups across all annular sizes (upsizing vs. control: 23 mm; 12.9 ± 8.2 vs. 14.0 ± 5.6 mm Hg, <i>p</i> = 0.029; 25 mm; 10.8 ± 4.0 vs. 13.0 ± 4.4 mm Hg, <i>p</i> < 0.001; 27 mm; 10.8 ± 4.0 vs. 13.0 ± 4.4 mm Hg, <i>p</i> < 0.001). Differences persisted at long-term follow-up but were less pronounced for the 25-mm annular size and greatest in the 27-mm group (8.5 ± 4.5 vs. 12.5 ± 5.5 mm Hg; <i>p</i> < 0.001). Long-term survival was numerically higher in the upsizing groups with statistical significance in annular size 25 mm.Implanting a larger Epic Supra prosthesis than classically recommended ("upsizing") is safe and associated with improved immediate- and long-term hemodynamics without increasing pacemaker, perioperative, or long-term mortality risks.