Two-directional aortic annular enlargement for aortic valve replacement in the small aortic annulus

Analysis of various techniques of aortic root enlargement

Prosthesis-patient mismatch after aortic valve replacement is associated with increased morbidity and mortality. A myriad of techniques have been described for aortic root enlargement to circumvent this problem. We review the salient techniques with their merits, demerits, and results.

Concomitant Annular Enlargement in Minimally Invasive Aortic Valve Replacement

OBJECTIVE

Aortic root enlargement may be necessary to implant adequately sized valves to avoid patient-prosthetic mismatch. Our objective was to assess the feasibility of annular enlargement during aortic valve replacement via a right anterior minithoracotomy.

METHODS

Twelve consecutive patients undergoing elective minimally invasive aortic valve replacement requiring annular enlargement over a 2-year period were retrospectively reviewed. A right anterior minithoracotomy was performed in all patients. Cardiopulmonary bypass and aortic crossclamp times, hospital length of stay, postoperative complications, rate of reoperation, echocardiographic data, and mortality were analyzed.

RESULTS

Mean age was 66 years ± 14. Mean body mass index was 34 ± 7.8 kg/m². All patients had normal preoperative ejection fractions. Indications for aortic valve replacement were severe (3/12, 25%) or critical (9/12, 75%) aortic stenosis due to degenerative aortic valve disease (10/12, 83%) and congenitally bicuspid aortic valve (2/12, 17%). Cardiopulmonary bypass and aortic crossclamp times were 144.7 ± 14.7 minutes and 111.7 ± 10.6 minutes, respectively. The median postoperative length of stay was 4 days. Peak and mean aortic valve gradients on postreplacement intraoperative transesophageal echocardiography were 14.5 ± 9.4 mmHg and 7.2 ± 4.2 mmHg, respectively, with no perivalvular leak on intraoperative or follow-up transthoracic echocardiogram. Postoperative transthoracic echocardiography had peak and mean aortic valve gradients of 12.1 ± 6.9 mmHg and 6.3 ± 3.7 mmHg, respectively. There were no postoperative mortalities. Freedom from reoperation was 100%.

CONCLUSIONS

Annular enlargement performed during minimally invasive aortic valve replacement is feasible. Basic minimally invasive skills are recommended prior to instituting these more advanced techniques.

Early and Midterm Results of Aortic Annular Enlargement

From November 1987 to May 1998, 16 patients with a small aortic annulus underwent patch enlargement of the aortic valve by Nicks' technique (in 9) or Manouguian's method (in 7). The mean age of the patients was 40 years (range, 22 to 58 years), mean body surface area was 1.54 m2 (range, 0.95 to 2.05 m2), and 11 were female. Concomitant procedures were mitral valve replacement in 4 cases, tricuspid commissurotomy and De Vega annuloplasty in 2, and one case each of patent ductus arteriosus ligation and coronary bypass. Aortic annular sizes were 15 to 19 mm (mean, 17.4 mm) preoperatively and 20 to 24 mm (mean, 22.1 mm) after the procedure. Two patients (12.5%) died in the early postoperative period. Peak pressure gradients across the prostheses were 15 to 22 mm Hg (mean, 19.4 mm Hg) on echocardiography. The mean duration of follow-up was 32.85 months (3 months to 8 years) and it was 92.8% complete. There were no late deaths. Mitral valve function was good except in one patient who had minimal mitral regurgitation after Manouguian's procedure. Both methods were found to be effective and reliable and should be performed when there is a risk of patient-prosthesis mismatch.

Aortoventriculoplasty after a prior posterior root enlargement (Manougian): case report

A patient with congenital bicuspid aortic stenosis had an open commissurotomy followed 3 years later by a Manougian's operation along with an aortic valve replacement. Nine years later, due to residual aortic stenosis, a Konno's anterior root enlarging procedure with an aortic valve replacement was successfully done. Good relief of aortic and subaortic stenosis and the absence of significant gradient across the left ventricular outflow tract led us to believe that successful and effective relief could be obtained by adding a Konno-type of enlargement to a previously performed posterior enlargement procedure.