Aortic valve replacement with mechanical prosthesis in small aortic annulus: Keep it simple!

We read with great interest the systematic review from Agarwal and colleagues, comparing the results of sutureless valves versus conventional aortic valve replacement (AVR) with aortic root enlargement in patients with aortic stenosis and small aortic annulus. We herein comment on the review trying to highlight some major issues. Based on some recent literature's evidences and on the authors' personal experience, we suggest to consider AVR with mechanical valve as a still viable option, especially in small aortic annulus. Indeed, root enlargement techniques are not always easy to perform and sutureless valve is still burdened by higher rate of PM implantation.