Comparison of Mortality and Morbidity in Patients Undergoing Aortic Valve Replacement With or Without Aortic Root Enlargement

Background Surgical aortic valve replacement (SAVR) remains the standard treatment for many patients with severe aortic valve disease. Implantation of a small prosthetic valve may result in prosthesis-patient mismatch (PPM), which adversely affects postoperative valve hemodynamics and long-term outcomes. Aortic root enlargement (ARE) has been proposed as a technique to facilitate the implantation of larger prosthetic valves; however, evidence from Indian populations remains limited. Methodology This prospective, observational study was conducted at Nizam’s Institute of Medical Sciences, Hyderabad, over one year (2024-2025). A total of 40 patients undergoing AVR were included, of whom 22 underwent aortic valve replacement (AVR) alone, and 18 underwent AVR with ARE. Data were collected retrospectively and prospectively. Inclusion criteria comprised patients with moderate/severe symptomatic aortic stenosis or chronic severe aortic regurgitation undergoing elective SAVR. Exclusion criteria included active infection, prior prosthetic valves, or significant surgical risks. Data on demographics, preoperative variables, intraoperative details, and postoperative outcomes were collected using structured formats. Effective orifice area index was calculated to grade PPM severity. Statistical analysis included t-tests, chi-square test, Mann-Whitney U test, Kaplan-Meier survival, and logistic regression, with significance set at p-values <0.05. Results The median age of study subjects (n = 40) was 65.1 years (interquartile range = 53.2-71.3), with a female predominance (55%). Common comorbidities were hypertension (22/40, 55%), dyslipidemia (19/40, 47.5%), and diabetes mellitus (9/40, 22.5%). Preoperatively, 26 (65%) patients were categorized as New York Heart Association class III. Aortic stenosis (13/40, 32.5%) and mixed lesions (24/40, 60%) were the main pathologies. The mean implanted valve size was smaller in the ARE group than in the AVR group (21.2 mm vs. 23.5 mm; t(38) = 2.05, p = 0.047). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were significantly longer in the ARE group (CPB: U = 107, p < 0.05; cross-clamp: t(38) = −2.07, p < 0.05). Postoperative mortality was comparable between groups (2/40, 5%; χ²(1) = 0.021, p = 0.884). The ARE group had a longer postoperative length of stay (median = 13 vs. 8 days; U = 80, p < 0.001). PPM occurred less frequently after ARE (χ²(3) = 9.045, p = 0.028); 26 patients (65%) had no PPM, and severe PPM was observed only in the AVR group. Kaplan-Meier analysis showed no difference in survival between groups over six months. Acute kidney injury was strongly associated with mortality (χ²(1) = 25.97, p = 0.004). Logistic regression identified female gender and lower effective orifice area as significant predictors for undergoing ARE. Conclusions This study highlights that ARE during AVR appears to be a safe adjunct procedure with comparable operative mortality or major complications in short-term follow-up. It effectively reduces the risk of PPM and allows implantation of larger prosthetic valves, which is particularly relevant in populations with smaller annuli. Although associated with longer operative and recovery times, ARE provides hemodynamic benefits without compromising short-term survival. These findings support the selective use of ARE in patients at risk for PPM to optimize surgical outcomes.