A Statewide Quality Initiative to Promote Aortic Annular Enlargement: Leading an Evolving Paradigm Shift.

Abstract

Aortic annular enlargement (AAE) represents an important adjunct strategy during aortic valve replacement (AVR), enabling implantation of a larger prosthesis to prevent patient-prosthesis mismatch. This study evaluated the results of a statewide quality improvement intervention (QII) to increase AAE adoption, including the novel Y-incision technique. 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 in May 2023 featuring wet laboratory training in AAE techniques. Patients were assigned to pre-QII (before September 2021) and post-QII groups. Primary end points were AVR+AAE incidence and median prosthesis size; secondary end points included 30-day mortality, transfusions, and morbidity. Sensitivity analyses were performed on isolated AVR+AAE cases. A total of 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 < .001), with isolated AVR+AAE cases rising from 8% to 23% (P < .001). Median prosthesis size increased from 23 to 25 mm (P < .001). Y-incision adoption rose significantly (20% vs 70%; P < .001), with more surgeons implementing the technique in the post-QII group (18 vs 35). No significant differences were observed in secondary end points. Sensitivity analyses confirmed findings. A pilot QII enhanced AAE adoption during AVR, leading to a larger aortic valve prosthesis without a significant increase in morbidity or mortality. Future research should explore midterm and long-term benefits on patient outcomes, including quality of life and survival.