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

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.