Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes

OBJECTIVE

To evaluate the safety and efficacy of a novel aortic annular enlargement technique.

METHODS

From August 2020 to February 2022, 50 consecutive cases of aortic valve replacement with Y-incision aortic annular enlargement and other combined cardiac procedures were performed primarily for severe aortic stenosis. Data were obtained through medical record review, The Society of Thoracic Surgeons database, and National Death Index data.

RESULTS

The median age was 65 (59, 71) years, 70% of patients were female, and 26% had previous cardiac surgery. Sixty-six percent patients had isolated aortic valve replacement. The preoperative mean gradient was 40 (30, 47) mm Hg, and the native aortic annular size was 21 (19, 23) mm. After aortic annular enlargement, the median prosthesis size was 27 (27, 29) with 54% of patients having a size 29 or the largest sized valve. The median increment of annulus enlargement was 3 (3, 4) valve sizes. 88% of patients received no blood transfusion. There were no major postoperative complications, including operative mortality, renal failure requiring permanent dialysis, mediastinitis, or reoperation for bleeding, except for 1 stroke. Three-month postoperative computed tomography aortogram showed the aortic root was enlarged from 27 (24, 30) to 40 (36, 41) mm without aortic pseudoaneurysm. The postoperative mean gradient was 7 (5, 8) mm Hg and valve area was 1.9 (1.7, 2.3) cm2 at 3 to 12 months. Mitral and tricuspid valve functions were significantly improved. Survival was 100% at 18 months.

CONCLUSIONS

Y-incision aortic annular enlargement was safe and effective for upsizing the aortic annulus by 3 to 4 valve sizes.

Aortic root enlargement and replacement of the ascending aorta in type 0 aortic valve stenosis

INTRODUCTION

This case report aims to describe an aortic root enlargement in combination with the replacement of the ascending aorta in a patient presenting with severe aortic valve stenosis.

CASE REPORT

A 68-year-old woman with severe aortic stenosis due to a type 0 bicuspid aortic valve and an aortic aneurysm underwent surgery for treatment. The annulus was preoperatively measured with 19 mm. Enlargement was performed by using a tissue patch to create a neo-noncoronary sinus and enlarge the root.

DISCUSSION

Patients with a small aortic root face an increased risk of patient prosthesis mismatch. Enlarging the aortic root can mitigate this, but it extends cross-clamp and overall operative times. This case shows the need for carefully planned surgical interventions to optimize outcomes in complex anatomies.

CONCLUSIONS

Each step of the performed surgery is well-established, however the combination and the creation of a neo-noncoronary sinus is not described so far.

How-I-Do-It: Aortic Annular Enlargement - Are the Nicks and Manouguian Obsolete?

The Y-incision aortic annular enlargement (AAE), first performed in August 2020, offers a safe and more effective alternative for management of a small aortic annulus/root without need for violation of the left ventricular outflow tract, mitral valve geometry, or left/right atria in both first-time aortic valve replacement (AVR) and reoperative AVR. In the first consecutive 119 patients with Y-incision AAE, the median age was 65 (59, 71), 67% female, 28% had previous cardiac surgery, and 2 cases had endocarditis. The preoperative mean gradient was 36 (30, 47), and the native aortic valve area was 0.9 (0.7, 1.0). After aortic annular enlargement, the median prosthesis size was 29 (27, 29) with 63% of patients having a size 29 or the largest sized valve. The median increment of annulus enlargement was 3 (3, 4) valve sizes. Postoperative complications included 1 operative mortality, 1 stroke exacerbation, and 2 pacemaker implantations (including one case of endocarditis with Gerbode fistula). There was no renal failure requiring permanent dialysis, mediastinitis, or reoperation for bleeding. Postoperative computed tomography aortogram showed the aortic root was enlarged from 27 (24, 30) to 40 (37, 42) mm without aortic pseudoaneurysm. The postoperative mean gradient was 6 (5, 9) mm Hg and valve area was 2.2 (1.8, 2.6) cm2 at 24 months. Mitral and tricuspid valve functions were significantly improved. This report describes the Y-incision technique with the most up-to-date modifications and short-term outcomes.

Aortic root enlargement in patients undergoing mitral and aortic replacement: early outcomes in a sub-Saharan population

Introduction

Aortic root enlargement (ARE) is often required to avoid patient-prosthesis mismatch (PPM) in young patients undergoing aortic surgery, including those undergoing combined mitral and aortic valve replacement (double valve replacement, DVR). Adding ARE to DVR may increase the operative risk by extending the surgical time. Herein, we review our experience with ARE in patients who underwent DVR.

Materials and methods

The medical records of 69 patients who underwent DVR at our institution between February 2008 and November 2021 were retrospectively reviewed. The patients were divided into two groups according to the ARE procedure (ARE-DVR: 25 patients; DVR: 44 patients). Descriptive and comparative analyses of demographic, clinical, and surgical data were performed.

Results

Among the 69 patients who underwent DVR, 35 were women (sex ratio, 0.97). The mean age at surgery was 26.7  ±  13.9 years (range: 7-62 years). Among the 47 patients aged ≤30 years, 40.4% (19/47) were aged between 10 and 20 years, and 6.3% (3/47) were aged <10 years. Patients in the ARE-DVR group were younger (23.3 ± 12.9 years vs. 28.5 ± 14.2 years, p < 0.05). The New York Heart Association Class ≥III dyspnea was the most common symptom (89.9%), with no differences between the two groups. Of all the patients, 84.1% had sinus rhythm. Rheumatic disease was the most common etiology in the entire cohort (91.3%). The mean aortic annulus diameter was 20.54 mm, with smaller sizes found in the ARE-DVR group (18.00 ± 1.47 mm vs. 22.50 ± 2.35 mm, p < 0.05). The aortic cross-clamping duration was greater in the ARE-DVR group (177.6 ± 37.9 min vs. 148.3 ± 66.3 min, p = 0.047). The operative mortality rate was 5.6% for the entire cohort (ARE-DVR: 8% vs. DVR: 4.5%, p = 0.46). Among the patients who underwent echocardiographic control at follow-up, the mean aortic gradient was 19.6 ± 7.2 mmHg (range: 6.14-33 mmHg), with no differences among the groups.

Conclusion

The association between ARE and DVR did not significantly affect operative mortality. ARE can be safely used whenever indications arise to reduce the occurrence of PPM, especially in young patients with growth potential.

Prosthesis-Patient Mismatch and Aortic Root Enlargement: Indications, Techniques and Outcomes

Prosthesis-patient mismatch (PPM) is defined as implanting a prosthetic that is insufficiently sized for the patient receiving it. PPM leads to high residual transvalvular gradients post-aortic valve replacement and consequently results in left ventricular dysfunction, morbidity and mortality in both the short and long term. Younger patients and patients with poor preoperative left ventricular function are more vulnerable to increased mortality secondary to PPM. There is debate over the measurement of valvular effective orifice area (EOA) and variation exists in how manufacturers report the EOA. The most reliable technique is using in vivo echocardiographic measurements to create tables of predicted EOAs for different valve sizes. PPM can be prevented surgically in patients at risk through aortic root enlargement (ARE). Established techniques include the posterior enlargement through Nicks and Manouguian procedures, and aortico-ventriculoplasty with the Konno-Rastan procedure, which allows for a greater enlargement but carries increased surgical risk. A contemporary development is the Yang procedure, which uses a Y-shaped incision created through the non- and left-coronary cusp commissure, undermining the nadirs of the non- and left-coronary cusps. Early results are promising and demonstrate an ability to safely increase the aortic root by up to two to three sizes. Aortic root enlargement thus remains a valuable and safe tool in addressing PPM, and should be considered during surgical planning.

Sutureless valves versus aortic root enlargement for aortic valve replacement in small aortic annulus: A systematic review and pooled analysis

BACKGROUND

Very few studies provide direct comparisons between aortic root enlargement and sutureless valve implantation in patients with a small aortic annulus who underwent aortic valve replacement. This study aims to provide comparative outcomes between the two in such a subset of patients, through a systematic review and pool analysis.

METHODS

The PubMed, Scopus and Embase databases were searched using the appropriate terms. The data from original articles mentioning aortic root enlargement and sutureless valves in a single or comparative study with another group of patients with a small aortic annulus were pooled and analyzed using descriptive statistics.

RESULTS

Both cardiopulmonary bypass (68.4 vs. 125.03 min, p < 0.001) and aortic cross-clamp times were significantly shorter in the sutureless valve group, along with a concomitantly higher number of minimally invasive surgeries. The incidence of permanent pacemaker implantation (9.76% vs. 3.16%, p < 0.00001), patient prosthesis mis-match and paravalvular leak was significantly higher in the sutureless valve group. In comparison, the incidence of re-exploration for bleeding was higher in the aortic root enlargement group (5.27% vs. 3.16%, p < 0.02). The two groups had no differences in the duration of hospital stays or mortality.

CONCLUSIONS

Sutureless valves demonstrated a comparable hemodynamic outcome with aortic root enlargement in patients with a small aortic annulus. In addition to this, it greatly facilitated minimally invasive surgery. However, the high incidence of pacemaker implantation is still a concern for the widespread recommendation of sutureless valves, especially in young patients with a small aortic annulus.

Aortic root abscess and anomalous aortic origin of right coronary artery in a 5-year-old child

BACKGROUND

Aortic root abscess is a rare complication of infective endocarditis in children.

CASE REPORT

A 5-year-old boy with infective endocarditis of aortic valve and an anterior aortic root abscess was found to have anomalous aortic origin of right coronary artery from the left coronary sinus on computed tomography scan with contrast.

RESULT

He was managed surgically by "patch and prosthesis" approach and required aortic root enlargement. Since anomalous aortic origin of right coronary artery is a relative contraindication for a Konno-Rastan aortic root enlargement, a Manouguian procedure was performed.

CONCLUSION

Anterior aortic root abscesses are rare, the co-existence of anomalous aortic origin of right coronary artery is rarer still and such cases requiring aortic root enlargement are possibly best served by a Manouguian procedure.

Aortic root enlargement: Just do it

Aortic root enlargement (ARE) can be an important adjunct for aortic valve replacement (AVR) in patients with small annuli, but incremental morbidity of this procedure is not well understood.

Early evaluation of the aortic root after Nicks' procedure

Objective(s)

To determine the influence of surgical techniques adopted to avoid suture line disruption, periprosthetic leakage, patch dislodgement, pericardial patch aneurysm formation, and the long-term stability of aortic root enlargement (ARE) during aortic valve replacement (AVR).

Methods

One hundred fifteen patients undergoing AVR or combined aortic and mitral valve replacements with Nicks' posterior ARE between 1997 and 2019 underwent long-term echocardiographic and angio-computed tomographic evaluation. Age was 11-72 years (AVR: median, 30; interquartile range, 21-47 years; AVR and mitral valve replacement: median, 27.5; interquartile range, 20-37.5 years). The aortotomy was closed using autologous pericardial patch and Teflon-buttressed sutures.

Results

Hospital mortality was 1.7% (n = 2), with 4 (3.5%) late deaths. At a mean follow-up of 123.11 ± 77.67 months, the survival probability from Kaplan–Meier was 93.25 ± 0.03%. No cases of severe prosthesis–patient mismatch (PPM) were observed, and only 2 patients had moderate PPM. Median aortic root diameters at the level of sinus of Valsalva and sinotubular junction were 32 (29-35) mm and 33 (30-36) mm, respectively, at discharge, and were 33 (30-36) mm, and 33 (31-37) mm, respectively, at latest follow-up, with no cases of late pericardial patch aneurysm.

Conclusions

ARE is a safe adjunct to AVR in patients with a small aortic annulus to prevent PPM. Retention of a pericardial collar and Teflon-buttressed sutures is an expedient, safe, and effective technique in reducing bleeding at the enlarged ventriculo-aortic junction. Autologous pericardial patch aortoplasty is not associated with late aneurysm/pseudoaneurysm formation.

A New Surgical Approach for Aortic Root Aneurysm and Small Aortic Annulus

Reconstruction of the aortic root in patients with aortic root aneurysm and small aortic annulus is an intricate surgical procedure. Here, we describe our technique performed in 2 patients, that involved aortic root enlargement with grafting in conjunction with annular implantation of the composite graft with a prosthetic mechanical valve, which allowed us to avoid incompatibility. This novel method offers an alternative combined surgical approach for patients with small aortic annulus and aortic root aneurysm that preserves the structure of the valved conduit at the level of the aortic annulus.

Aortic Root Enlargement and Aortic Valve Replacement for Calcified Supravalvular and Valvular Aortic Stenosis in Homozygous Familial Hypercholesterolemia: A Case Report

Familial homozygous hypercholesterolemia is a rare disease with diverse clinical presentations ranging from premature ischemic heart disease to aortic root stenosis but rarely presents with anginal symptoms due to supravalvular and valvular aortic stenosis. We report a 19-year-old male patient with familial homozygous hypercholesterolemia with progressive supravalvular and valvular aortic stenosis that ultimately required aortic root enlargement and aortic valve replacement using a mechanical prosthesis, despite aggressive medical therapy. Surgical importance of this rare condition is highlighted.

Aortic Root Enlargement or Sutureless Valve Implantation?

Aortic valve replacement (AVR) in patients with a small aortic annulus is a challenging issue. The importance of prosthesis–patient mismatch (PPM) post aortic valve replacement (AVR) is controversial but has to be avoided. Many studies support the fact that PPM has a negative impact on short and long term survival. In order to avoid PPM, aortic root enlargement may be performed. Alternatively and keeping in mind that often some comorbidities are present in old patients with small aortic root, the Perceval S suturelles valve implantation could be a perfect solution. The Perceval sutureless bioprosthesis provides reasonable hemodynamic performance avoiding the PPM and providing the maximum of aortic orifice area. We would like to see in the near future the role of the aortic root enlargement techniques in the era of surgical implantation of the sutureless valve (SAVR) and the transcatheter valve implantation (TAVI).

Anatomic Correlation of Posterior Aortic Root Enlarging Incisions

OBJECTIVES

To clarify the terms surrounding the posterior aortic root enlarging incisions and correlate them anatomically.

METHODS

This is a human cadaveric heart study in which measurements were taken along the path of the named incisions in 42 normal and congenitally malformed hearts using calipers.

RESULTS

Our results indicate that there is a variable overlap of the left atrial wall with the anterior mitral leaflet and the aorta and that in individual cases it may not be possible to accurately predict the possibility of enlarging the root without opening the left atrium, though some papers suggest otherwise.

CONCLUSION

Names associated with incisions are best avoided. Rather they should be described anatomically. Incision between the noncoronary sinus of Valsalva and left coronary sinus of Valsalva may be the safest approach to enlarging the root.