European Journal of Cardiovascular Medicine

Aortic root enlargement (ARE) is a well-established surgical procedure aimed at addressing small aortic root that can occur in patients with aortic valve disease (1). The aortic root, which includes the aortic valve and the adjacent structures, plays a crucial role in maintaining normal cardiac function and ensuring effective blood flow from the left ventricle into the aorta. Structural abnormalities in this area, such as annular dilatation, valve calcification, or congenital deformities, can lead to significant hemodynamic compromise. These abnormalities often require surgical intervention, with aortic valve replacement (AVR) being the most common procedure performed to restore normal valve function (2). In cases where the aortic root is narrow, aortic root enlargement is performed in conjunction with AVR to optimize surgical outcomes and ensure proper valve function (3).

The need for aortic root enlargement arises when the aortic annulus is narrow, making it difficult to properly seat a proper size valve prosthesis. This situation can occur due to a variety of causes, including congenital valve abnormalities, such as bicuspid aortic valve, or acquired conditions such as severe aortic stenosis (AS) and rheumatic heart disease (RHD). In addition, degenerative calcification of the aortic valve, particularly in older adults, can lead to severe stenosis and regurgitation, both of which are associated with significant morbidity and mortality if left untreated (4). Therefore, aortic root enlargement procedures are often necessary to improve the outcomes of AVR and restore normal cardiac function and to implant proper size prosthesis to avoid Patient prosthesis mismatch (PPM).

The concept of aortic root enlargement was first introduced in the late 20th century as a means of addressing these issues. It involves the use of various techniques, such as pericardial patches, bovine pericardial patches, or other synthetic materials, to expand the aortic root and enable optimal placement of the valve prosthesis. This procedure not only addresses the anatomical challenges of the aortic root but also improves hemodynamic function by reducing gradients across the valve and improving left ventricular ejection fraction (LVEF) (5). The use of pericardial patches in particular has gained widespread acceptance, as it provides a natural material that is biocompatible and durable. These materials help to create an appropriately sized aortic root and ensure proper function of the prosthetic valve, thus improving the overall success of the surgery (6).

Aortic root enlargement procedures are often performed alongside other interventions, such as mitral valve replacement (MVR), tricuspid annuloplasty, or other corrective surgeries. In cases where patients present with multiple valve pathologies, such as aortic stenosis combined with mitral stenosis or regurgitation, a multi-valve approach is often necessary. This is particularly true in patients with rheumatic heart disease or other conditions that lead to multi-valve involvement. These patients often experience complex surgical challenges, and the success of the procedure relies on a thorough understanding of the hemodynamic and anatomical factors at play (7).

In addition to the technical challenges involved in aortic root enlargement, the timing of the procedure is also critical. Delayed intervention in patients with severe aortic valve disease and aortic root abnormalities can lead to irreversible damage to the left ventricle, resulting in reduced left ventricular function and a poor long-term prognosis. Therefore, timely surgical intervention is crucial to improving patient outcomes. Several studies have demonstrated that early intervention with AVR and aortic root enlargement significantly improves survival rates and quality of life in patients with severe aortic valve disease (8). Furthermore, advancements in surgical techniques and valve prosthetics have improved the safety and efficacy of these procedures, making them more accessible to a broader range of patients.

The benefits of aortic root enlargement extend beyond just the immediate surgical outcome. Post-operative recovery and long-term survival are significantly improved in long term. In many cases, patients experience a significant improvement in left ventricular ejection fraction (LVEF), a key marker of cardiac function. In addition, the procedure helps to alleviate symptoms such as dyspnea, chest pain, and fatigue, which are common in patients with severe aortic valve disease. Moreover, the reduction in valve gradients and improvement in hemodynamics contribute to better overall cardiovascular health, reducing the burden on the heart and improving long-term outcomes (9).

Despite the positive outcomes associated with aortic root enlargement, there are also risks and complications associated with the procedure. These include potential bleeding, infection, and the possibility of valve dysfunction or paravalvular leaks. However, with proper surgical technique and careful post-operative monitoring, these complications can be minimized. Additionally, long-term follow-up is essential to ensure the continued function of the prosthetic valve and the success of the aortic root enlargement procedure. Regular echocardiographic assessments are typically performed to monitor valve function, gradient levels, and left ventricular function (10).

This study aims to contribute to the existing body of knowledge regarding the outcomes of aortic root enlargement procedures by presenting the experience of a cohort of 37 patients who underwent this intervention. By analyzing the demographic data, pre-operative and post-operative echocardiographic findings, surgical outcomes and most important the morbidity and  long term follow up, this study seeks to provide valuable insights into the efficacy of aortic root enlargement in improving valve function and overall cardiac health. Moreover, the findings of this study will help refine surgical strategies for patients with complex aortic valve disease and aortic root abnormalities, ultimately improving patient outcomes and contributing to the continued advancement of cardiovascular surgery.

Study Design:

This study utilized a prospective observational design. The aim was to review and analyze the medical records of patients who underwent aortic root enlargement in combination with aortic valve replacement at our institution. This study was designed to investigate long term follow up the outcomes of aortic root enlargement procedures and post-operative morbidity, improvements in valve function, left ventricular ejection fraction (LVEF), and other associated cardiovascular outcomes. Data were extracted from patient files, and pre-operative, intra-operative, and post-operative data were analyzed to evaluate the efficacy of the procedure and the overall surgical outcomes.

Study Setting:

The study was conducted at a Bombay Hospital Institute of Medical Sciences, Mumbai. This hospital has a specialized cardiac surgery unit that deals with a variety of complex cardiovascular conditions. The institution has a well-established protocol for the management of patients requiring aortic root enlargement and aortic valve replacement. The surgical team consisted of experienced cardiothoracic surgeons, with an excellent track record of performing valve surgeries and aortic root interventions.

Study Duration:

The study was conducted prospectively over a period of 26 years, from 1998 to 2024. This duration allowed for a comprehensive analysis of patient outcomes post-surgery, as patients were followed up for an average of yearly after their procedures. The extended duration enabled us to gather sufficient data on both short-term and long-term outcomes, which included long term survival, post-operative complications, recovery patterns, and overall survival rates.

Participants - Inclusion and Exclusion Criteria:

Inclusion Criteria:

• Patients who underwent aortic valve replacement in conjunction with aortic root enlargement at the institution.
• Patients diagnosed with severe aortic stenosis (AS) or congenital abnormalities (e.g., bicuspid aortic valve) that necessitated both AVR and aortic root enlargement.
• Patients who had complete medical records, including pre-operative, intra-operative, and post-operative echocardiographic data.
• Patients who underwent follow-up echocardiography post-surgery.

Exclusion Criteria:

• Patients who did not undergo aortic root enlargement along with aortic valve replacement.
• Patients with incomplete medical records or missing critical data.
• Patients who had undergone prior aortic root enlargement surgeries.
• Patients with other significant comorbidities such as advanced heart failure, renal failure, or uncontrolled diabetes that could skew the outcomes of the study.

Study Sampling:

The study utilized a non-random convenience sampling technique, where the medical records of patients who met the inclusion criteria were selected for analysis. This sampling method was chosen due to the nature of the study and the specific focus on patients who had undergone aortic root enlargement in combination with aortic valve replacement. All eligible patients who underwent surgery between 1998 and 2002 were included, with no randomization process involved.

Study Sample Size:

A total of 37 patients were included in the study (Study Cohort). This sample size was determined based on the number of patients who underwent aortic root enlargement procedures during 1998 to 2002. Given the prospective nature of the study, the sample size was constrained by the number of available cases that met the inclusion criteria. The sample was considered sufficient to provide meaningful data for analysis, given that these patients represented a cross-section of those undergoing this procedure at our institution and were in follow up till 2024.

Study Parameters:

The following parameters were assessed to evaluate the outcomes of the aortic root enlargement procedure:

• Pre-operative Parameters:
• 2D echocardiographic findings including aortic valve area, left ventricular ejection fraction (LVEF), and degree of aortic stenosis or regurgitation.
• Patient demographic data such as age, sex, and history of comorbid conditions.
• Intra-operative Parameters:
• Type of valve prosthesis used (e.g., St. Jude, On-X, or other mechanical valves).
• The technique of aortic root enlargement (e.g., pericardial patch, synthetic materials).
• Post-operative Parameters:
• Post-operative echocardiographic findings including valve function, aortic valve gradients, and left ventricular ejection fraction (LVEF).
• Incidence of post-operative complications such as paravalvular leaks, residual regurgitation, or infection.
• Recovery metrics, including length of hospital stay, return to normal activities, long-term follow-up, and survival rates.

Study Procedure:

The study followed a prospective design, where medical records of patients who underwent the procedure were reviewed and followed up till study duration period of 26 years (January 1998 to December 2024). Operative Data was taken from the hospital’s electronic medical records and physical charts. The pre-operative, intra-operative, and post-operative data were collected. The patients’ medical charts contained detailed information regarding their echocardiographic findings, valve replacement details, surgical procedures performed, and the type of materials used for the aortic root enlargement. Post-operative data was gathered from follow-up echocardiograms, surgical notes, and clinical reports.

The study also involved reviewing follow-up appointments, where patients underwent routine echocardiographic assessments to monitor valve function and identify any complications.

Study Data Collection:

Data collection was performed by a team of trained research assistants, Cardiac surgeons and cardiologists. The following steps were followed:

1. Review of the patients' medical records to identify relevant pre-operative data (echocardiographic findings, valve pathology, and LVEF).
2. Collection of intra-operative data, including type of valve prosthesis used and the surgical technique for aortic root enlargement.
3. Gathering of post-operative data, including symptoms, post-operative echocardiogram results, valve function, gradients, and LVEF.
4. Follow-up data were reviewed to assess long-term outcomes, such as procedure durability and survival rates.

Data Analysis:

Data were analyzed using descriptive statistics to provide an overview of patient demographics, surgical details, mortality, morbidity and long-term outcomes. The results were presented as means and standard deviations for continuous variables (e.g., age, LVEF) and percentages for categorical variables (e.g., valve type, complications). Comparative analyses were performed using paired t-tests for continuous variables to assess pre- and post-operative changes in LVEF and valve gradients. The relationship between variables was assessed using correlation coefficients. Statistical significance was set at a p-value of <0.05. The data analysis was conducted using statistical software such as SPSS (Statistical Package for Social Sciences).

Ethical Considerations:

Patient confidentiality and consent were ensured and maintained by identifying personal information from the medical records before data analysis. The research team ensured that the study complied with the ethical guidelines outlined in the Declaration of Helsinki, which emphasizes the importance of patient privacy and the ethical use of medical data. All patient records were stored securely, and access was restricted to authorized personnel only.

1. Patient Demographics and Pre-operative Data

Interpretation: The demographic data shows that both male and female patients were fairly evenly distributed, with a slight majority of females (51.4%). Age-wise, the majority of patients were between 21 and 50 years, accounting for 59.4% of the study population. This indicates that aortic valve diseases and aortic root enlargement procedures are not limited to older adults and affect a wide age range. Severe aortic stenosis (AS) was the most common pre-operative diagnosis, affecting 27% of patients, followed by bicuspid aortic valve disease, and other mixed valve conditions. Rheumatic heart disease was seen in 8.1% of the patients, highlighting the importance of addressing advanced valve disease at an early stage.

Table 1: Patient Demographics and Pre-operative Data

2. Pre-operative and Post-operative Left Ventricular Ejection Fraction (LVEF)

Interpretation: Pre-operative LVEF values were relatively low, especially for patients with severe aortic stenosis and regurgitation, which is expected as these conditions impose a heavy workload on the heart. The study shows significant improvements in LVEF post-surgery, with a mean increase of 5-15%, demonstrating the effectiveness of aortic root enlargement in alleviating the strain on the left ventricle and improving cardiac output. These improvements are particularly notable in patients with severe AS, where the mean LVEF increased from 30% to 45%. In patients with preserved LVEF prior to surgery (e.g., those with bicuspid aortic valve), the improvement was more modest.

Table 2: Pre-operative and Post-operative Left Ventricular Ejection Fraction (LVEF)

3. Post-operative Valve Function and Complications

Interpretation: The post-operative echocardiographic findings indicate that a significant majority of patients (81.1%) experienced normal aortic prosthesis function, which reflects the success of the valve replacement and root enlargement procedure. However, a small percentage (10.8%) of patients had mild paravalvular leak, which is common in aortic root enlargement with valve replacement surgeries but did not impact the overall outcome. Trivial Tricuspid regurgitation (TR) and mitral regurgitation (MR) were observed in a minority of patients, but these were mostly mild and did not lead to major clinical consequences. The relatively low complication rate reinforces the procedure’s efficacy.

Table 3: Post-operative Valve Function and Complications

4. Aortic Root Enlargement Procedure Success

Interpretation: The success rate of the aortic root enlargement procedure was exceptionally high, with 100% procedural success. This confirms that the technique used was effective in treating the aortic root dilation, allowing for proper seating of the valve prosthesis. Root enlargement led to an average increase of 0.5 to 1.0 cm in root diameter, which is consistent with the literature that reports a favourable outcome for root enlargement procedures. Only a small percentage of patients (10.8%) experienced mild aortic paravalvular leaks, but these were easily managed and did not affect the overall results of the surgery.

Table 4: Aortic Root Enlargement Procedure Success

5. Post-operative Follow-up and Survival Rate

Interpretation: Follow-up data showed that the patients followed up for 26 years post-operatively. This extended follow-up is important for evaluating the long-term success of the procedure and ensuring the durability of the root enlargement with subsequent aortic valve replacement. The survival rate was 100% for 15 years, suggesting that the aortic root enlargement procedure, in combination with AVR, is a highly effective intervention. The absence of major complications and Major adverse cerebrovascular and cardiac events (MACCE) or reoperations is indicative of the procedure's safety and long-term benefits.

Table 5: Post-operative Follow-up and Survival Rate

6. Left Ventricular Ejection Fraction (LVEF) Improvement

Interpretation: The improvement in LVEF post-surgery is a critical indicator of the success of the aortic root enlargement procedure. For patients with severe aortic stenosis and regurgitation, the mean increase in LVEF was significant, with a 10-15% improvement in the majority of patients. This improvement correlates with reduced myocardial stress and better overall cardiac function post-surgery. For patients with preserved LVEF, the improvement was more modest, as expected. These results confirm that aortic root enlargement plays a vital role in enhancing cardiac output and improving patient quality of life.

This study aimed to evaluate the outcomes of aortic root enlargement procedures combined with aortic valve replacement (AVR) in 37 patients. The results from this study provide valuable insights into the effectiveness and our feasibility of our surgical approach for patients small  aortic roots requiring root enlargement and valve replacement including for severe aortic stenosis (AS). By analyzing pre-operative and post-operative data including echocardiographic findings, complications, and patient recovery, this study demonstrates that our technique of  aortic root enlargement is a highly effective procedure with no morbidity and mortality in our study group with significant improvements in valve function, left ventricular ejection fraction (LVEF) and long-term survival.

Demographics and Pre-operative Data

The patient cohort in this study comprised both male (48.6%) and female (51.4%) patients, with a majority of patients aged between 21 and 50 years, representing 59.4% of the study population. This suggests that aortic valve diseases are not limited to older adults, and younger patients also require such interventions, particularly for bicuspid aortic valve disease. Similarly, Nasir et al. (2024) reported a younger patient population, with an average age of 37.53 ± 15.59 years, reinforcing the notion that aortic valve pathologies frequently require surgical intervention at a relatively young age (11).

The most common pre-operative diagnosis in this study was severe aortic stenosis (rheumatic heart disease [RHD] and calcific aortic stenosis), affecting 86.5% of patients, followed by bicuspid aortic valve disease (13.5%). This prevalence aligns with findings from previous studies, including Shih et al. (2022) (12), where severe aortic stenosis was identified as a leading cause of aortic valve replacement, and Großmann et al. (2024), which specifically examined a case of severe aortic stenosis due to a type 0 bicuspid aortic valve (13). The presence of rheumatic heart disease in 8.1% of the patients in this study further highlights the ongoing need for interventions to treat valve diseases caused by inflammatory conditions, a finding that is also reflected in studies such as Nasir et al. (2024), where RHD was a notable contributor to valve pathology in the studied population (12). These comparisons reinforce the global prevalence of severe aortic stenosis and the necessity of surgical management, particularly in younger patients and regions where RHD remains a significant healthcare challenge.

Pre-operative and Post-operative Left Ventricular Ejection Fraction (LVEF)

Pre-operative left ventricular ejection fraction (LVEF) was notably reduced in patients with severe aortic stenosis (mean 30.5%), reflecting significant left ventricular strain, consistent with findings from Shih et al. (2022) and Sá et al. (2022) (12,14). Similarly, Nasir et al. (2024) reported reduced LVEF in patients requiring aortic root enlargement (ARE), reinforcing the detrimental impact of stenotic lesions on ventricular function (11). Post-operatively, LVEF improved significantly from 30.5% to 45% in severe aortic stenosis patients, while those with bicuspid aortic valve disease saw a smaller increase from 55% to 60%. These findings align with Nasir et al. (2024) and Großmann et al. (2024), which also reported improved cardiac function post-ARE (11,13). The improvements highlight the role of ARE with aortic valve replacement (AVR) in restoring valve function and alleviating ventricular strain. This aligns with Sá et al. (2022), which noted measurable improvements even in patients with moderate dysfunction (14). These comparisons confirm that aortic root enlergement (ARE) optimizes post-operative cardiac performance, particularly in severe aortic stenosis, improving both ventricular function and overall patient outcomes.

Post-operative Valve Function and Complications

Post-operative echocardiographic findings showed that 81.1% of patients had normal prosthetic valve function with very less gradients, confirming the effectiveness of aortic root enlargement (ARE) with aortic valve replacement (AVR). This aligns with findings from Shih et al. (2022) and Nasir et al. (2024), which also reported high prosthesis success rates post-ARE (11,12).

Mild aortic paravalvular leak was observed in 10.8% of patients, a known occurrence in ARE cases. Similarly, Sá et al. (2022) noted that minor leaks are generally well tolerated and rarely require intervention (14). Mild mitral regurgitation (21.6%) and mild tricuspid regurgitation (16.2%) were also detected but did not impact recovery. Großmann et al. (2024) highlighted similar post-operative findings, emphasizing that minor leaks do not compromise long-term outcomes (13). Overall, the study demonstrated a low rate of major complications, reinforcing the safety of aortic root enlargement (ARE). The minor paravalvular leaks observed were clinically insignificant, consistent with prior reports indicating that aortic root enlargement (ARE) can be performed successfully without severe valve dysfunction. These findings confirm that aortic root enlargement (ARE) optimizes prosthetic valve function while maintaining a favorable safety profile.

Aortic Root Enlargement Procedure Success

The aortic root enlargement (ARE) procedure demonstrated a 100% procedural success rate in both short-term and long-term follow-ups, emphasizing the efficacy of precise surgical techniques. This aligns with findings from Shih et al. (2022) and Nasir et al. (2024), where ARE was associated with optimal prosthetic valve placement and favorable post-operative outcomes (11,12). Aortic root enlargemnt enabled us to put higher (bigger) size valve prosthesis, where annulus is small. This success rate underscores the importance of using precise surgical techniques for aortic root enlargement. Already established and practiced technique for root enlargement was used in this study. Single stage venous cannulation was done with high aortic cannulation and oblique aortotomy extending upwards. Root enlargement was done by posterior approach through non coronary cusp extending into anterior mitral leaflet. Augmentation was done using autologously treated pericardial patch in continuous manner with prolene 4-0 suture. After ensuring adequately sized valve valve implantation was done by suturing the neo annulus along with native annulus in routine interrupted pledgetted ethibond sutures. Subsequent defect in the aorta resulting from the root augmentation was reconstructed by extension of the  same autologous pericardial patch used for root augmentation by suturing it in continuation with the aortic wall edges in continuous manner. The posterior approach through the non-coronary cusp, combined with autologous pericardial patch augmentation, allowed for an average root diameter increase of 0.5 to 1.0 cm, consistent with previous reports. Großmann et al. (2024) similarly highlighted the effectiveness of ARE in preventing patient-prosthesis mismatch (13). Sá et al. (2022) noted that ARE facilitates larger valve implantation, reducing left ventricular strain and improving overall cardiac function (14). Despite a 10.8% incidence of mild paravalvular leaks, no significant valve failures were observed, mirroring trends seen in Großmann et al. (2024), where minor leaks did not affect long-term outcomes (13). These results reaffirm ARE as a reliable surgical technique for optimizing valve function while minimizing complications. The technique we practised is a simple  and easily reproducible method with no risk of bleeding and lower morbidity.  Long term survival observed in our study emphasises avoiding reoperations required at later time particularly in our set up where patients get operated at early age comparatively than the western population and where patients cannot afford reoperations due to various financial and social constrains.

Post-operative Follow-up and Survival Rate

Follow-up data from this study showed a remarkable 100% survival rate for 15 years post-surgery, emphasizing the long-term safety and efficacy of aortic root enlargement (ARE) with aortic valve replacement (AVR). There was no re exploration for bleeding in immediate post operative period. This aligns with findings from Sá et al. (2022), which reported no significant differences in long-term survival between patients undergoing AVR with or without ARE (14). Similarly, Nasir et al. (2024) observed satisfactory short-term outcomes, reinforcing the durability of the procedure. The long follow-up period of 26 years is crucial for assessing procedural success (11). The absence of major complications or reoperations further supports the findings of Shih et al. (2022), which highlighted ARE’s role in optimizing prosthetic valve function without increasing operative mortality (12). Additionally, Großmann et al. (2024) emphasized that ARE improves valve implantation and hemodynamic stability, contributing to sustained positive outcomes (13). The high survival rate in this study underscores that ARE is a safe and reproducible technique, providing lasting benefits for patients requiring valve enlargement. These results confirm ARE as a reliable surgical approach with minimal complications and excellent long-term patient outcomes. Long term survival observed in our study emphasises avoiding reoperations required at later time particularly in our set up where patients get operated at early age comparatively than the western population and where patients cannot afford reoperations due to various financial and social constrains. Long term survival benefit observed in our study underlines the effectiveness of our technique.

In conclusion, this study demonstrates that aortic root enlargement, when combined with aortic valve replacement, is an effective and safe procedure for patients with complex aortic valve diseases. The results showed significant improvements in left ventricular ejection fraction, with an average increase of 10-15% in most patients, and normal function of the aortic prosthesis in 81.1% of cases. Although mild paravalvular leaks and mild Mitral regurgitation were observed in some patients, these were not clinically significant and did not necessitate further intervention. The high procedural success rate, combined with the 100% survival rate in the immediate post op period and up to 15 years with long term follow up of 26 years till maximum 24 years and minimal complications, underscores the effectiveness of this combined surgical approach in treating patients with severe aortic valve disease with small roots particularly observed in our set up. The technique we practised is a simple  and easily reproducible method with no risk of bleeding and lower morbidity.  Long term survival observed in our study emphasises avoiding reoperations required at later time particularly in our set up where patients get operated at early age comparatively than the western population and where patients cannot afford reoperations due to various financial and social constrains. Long term survival benefit observed in our study underlines the effectiveness of our technique. These findings support the use of this surgical approach as a viable treatment for stenotic aortic valve diseases in small aortic roots particularly in our set up where patients have narrow aortic roots.

Further research with larger cohorts and longer follow-up periods will help confirm these findings and explore the long-term durability of aortic root enlargement procedures

1. Yamaguchi T, et al. Surgical treatment of aortic root dilation. J Card Surg. 2005;20(3):278-283.
2. Kouchoukos NT, et al. Aortic root surgery: strategies for addressing dilation and dissection. Ann Thorac Surg. 2011;91(5):1241-1246.
3. Svensson LG, et al. Aortic root enlargement in valve replacement for severe aortic stenosis. J Thorac Cardiovasc Surg. 1998;116(4):525-531.
4. D'Orio V, et al. Aortic valve replacement in patients with bicuspid aortic valve disease. Heart Lung Circ. 2012;21(6):357-364.
5. Rivera F, et al. Aortic root enlargement for aortic valve replacement. Heart Surg Forum. 2000;3(2):107-111.
6. Vohra HA, et al. Aortic root reconstruction with bovine pericardial patch. Ann Thorac Surg. 2012;94(3):759-764.
7. Salameh A, et al. Surgical management of multi-valve heart disease: The role of aortic root enlargement. J Card Surg. 2009;24(5):463-469.
8. Dubois S, et al. Early versus late surgical intervention in aortic valve disease. Eur J Cardiothorac Surg. 2009;36(3):567-574.
9. Elefteriades JA, et al. Long-term outcomes of aortic root replacement. Circulation. 2011;124(23):2669-2678.
10. Lytle BW, et al. Early and late outcomes of aortic root enlargement in patients undergoing aortic valve replacement. Ann Thorac Surg. 1996;62(6):1344-1351.
11. Nasir A, Iqbal A, Haseeb A, Khan AH. Frequency of aortic root enlargement to prevent PPM in patients undergoing aortic valve replacement in Peshawar Institute of Cardiology. J Health Rehabil Res. 2024;4(1).
12. Shih E, DiMaio J, Squiers J, Rahimighazikalayeh G, Meidan TC, Brinkman W, et al. Outcomes of aortic root enlargement during isolated aortic valve replacement. J Card Surg. 2022;37(8):2389-94.
13. Großmann C, Krasivskiy I, Djordjevic I, Mihaylova M, Wahlers T, Eghbalzadeh K. Aortic root enlargement and replacement of the ascending aorta in type 0 aortic valve stenosis. Perfusion. 2024.

14. Sá MP, Van den Eynde J, Amabile A, Malin JH, Jacquemyn X, Tasoudis P, et al. Late outcomes after aortic root enlargement during aortic valve replacement: Meta-analysis with reconstructed time-to-event data. J Cardiothorac Vasc Anesth. 2022.