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

Trials comparing transcatheter aortic valve replacement and surgical aortic valve replacement (SAVR) have shown that in patients with annuli <26 mm, SAVR had negative hemodynamic and clinical outcomes. Recently, studies revealed that the effective orifice diameter of surgical prosthetic valves is 5-7 mm smaller than the labeled valve size. To improve outcomes of SAVR, the Y-incision aortic annular enlargement (AAE) enlarges the surgical aortic annulus to accommodate a prosthetic valve 3-4 sizes larger with an effective orifice area that matches the patient's native annulus. This review discusses when and how the Y-incision AAE should be performed.

OVID MEDLINE, OVID Embase, and Cochrane Library were searched with terms that included "Y-incision aortic annular enlargement," "valve sizes," and "long-term survival." The search included publications after 2020. The reference lists of included studies were reviewed to retrieve additional studies.

In patients with matched native annular sizes, AAE significantly improved midterm survival without increasing perioperative complications. Patients treated with a larger valve had notably better long-term survival and small valve sizes were significant risk factors for operative and long-term mortality. Compared with patients treated with a Nicks or Manougian procedure, the hemodynamics in patients treated with Y-incision AAE were significantly better.

Y-incision AAE could be routinely considered for patients with a normal annulus (17-25 mm) undergoing SAVR.