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Aortic Annular Enlargement: Y-Incision Rationale, Technique, and Outcomes.

Sarah A Chen1, Chi Chi Do-Nguyen2, Marc Titsworth2

  • 1Division of Cardiac Surgery, University of California, Davis, Sacramento, California.

The Annals of Thoracic Surgery
|February 1, 2025
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Summary

Y-incision aortic annular enlargement (AAE) improves surgical aortic valve replacement (SAVR) outcomes in patients with small annuli. This technique ensures a larger prosthetic valve fits, enhancing survival and hemodynamics compared to standard SAVR.

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Area of Science:

  • Cardiovascular Surgery
  • Cardiac Valve Repair & Replacement
  • Surgical Innovation

Background:

  • Surgical aortic valve replacement (SAVR) in patients with small aortic annuli (<26 mm) is linked to suboptimal hemodynamic and clinical outcomes.
  • Surgical prosthetic valves often have a smaller effective orifice diameter than their labeled size, contributing to poor results.
  • Y-incision aortic annular enlargement (AAE) is a technique to increase the aortic annulus size, allowing implantation of larger prosthetic valves and potentially improving outcomes.

Purpose of the Study:

  • To review the indications and methodology for performing Y-incision aortic annular enlargement (AAE).
  • To evaluate the impact of AAE on patient survival and perioperative complications.
  • To compare the hemodynamic performance of Y-incision AAE with other aortic annular enlargement techniques.

Main Methods:

  • Literature search of OVID MEDLINE, OVID Embase, and Cochrane Library using keywords: "Y-incision aortic annular enlargement," "valve sizes," and "long-term survival."
  • Inclusion of studies published after 2020.
  • Review of reference lists from included studies to identify additional relevant publications.

Main Results:

  • AAE significantly improved midterm survival in patients with matched native annular sizes, without increasing perioperative complications.
  • Implantation of larger prosthetic valves via AAE was associated with notably better long-term survival.
  • Y-incision AAE demonstrated significantly better hemodynamics compared to Nicks or Manougian procedures.

Conclusions:

  • Y-incision aortic annular enlargement (AAE) is a viable option for patients with normal-sized annuli (17-25 mm) undergoing SAVR.
  • Routine consideration of Y-incision AAE may be beneficial for select patients to optimize SAVR outcomes.
  • This technique addresses the issue of undersized prosthetic valves in patients with small native aortic annuli.