A New Technique for Aortic Annular and Outflow Enlargement: Combined Y-Incision and Nicks Procedures

In the valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) era, implanting a larger-sized valve during the initial aortic valve replacement is important. For smaller aortic annuli, combining aortic annular and left ventricular outflow tract (LVOT) enlargement is essential. The Y-incision procedure helps achieve implantation of a 2-size larger valve. However, it can lead to size discrepancies between the valve and the LVOT, thus resulting in a residual pressure gradient, and the risk of coronary obstruction after ViV-TAVR remains because the initial surgical valve is implanted tilted inward. To resolve these concerns, we combined the Y-incision and Nicks procedures.