Double valve replacement with ring enlargement: A case report

Rheumatic multivalvular disease is typically associated with annular narrowing, especially of the aortic valve, and even more so when it is accompanied by mitral valve involvement.

A 60-year-old woman with a history of rheumatic mitral valve disease previously treated with open-heart mitral commissurotomy presented with NYHA class III dyspnea, progressively worsening over the past six months. Physical examination revealed a body mass index (BMI) of 25 and a body surface area (BSA) of 1.6 m². There were no signs of heart failure. The pulse was irregular, with a systolic murmur heard at the mitral area and a diastolic murmur at the aortic area. Transthoracic echocardiography revealed both mitral and aortic valve disease, predominantly regurgitant in nature, with significant retraction and calcification of the leaflets. Notably, there was annular narrowing, especially of the aortic annulus. These findings were associated with severe tricuspid regurgitation and marked dilation of the right heart chambers. Left ventricular function was preserved. The patient underwent surgery under cardiopulmonary bypass. Intraoperative inspection revealed thickened and retracted aortic cusps, along with a small aortic annulus that could not accommodate a No. 19 Hegar dilator. Therefore, an aortic annulus enlargement using the Manouguian technique was performed, along with mitral valve replacement and tricuspid annuloplasty. A No. 21 mechanical prosthesis was implanted in the aortic position to prevent patient-prosthesis mismatch, a No. 29 mechanical prosthesis was placed in the mitral position, and a No. 32 tricuspid ring was inserted. The postoperative course was uneventful, and the patient was discharged on postoperative day four.

The management of a small aortic root during aortic valve replacement (AVR) has been a subject of discussion in cardiac surgery for over three decades and remains controversial. Several techniques have been developed to enlarge a narrowed aortic root and prevent patient-prosthesis mismatch (PPM). The challenge of implanting an aortic prosthesis becomes even more pronounced in patients with concomitant mitral valve disease. In such cases, insertion of the aortic prosthesis following mitral valve replacement is often more difficult than in patients with a normal or enlarged aortic root. When performing double valve replacement (DVR), enlargement of the aortic annulus-or both the aortic and mitral annuli-may be required to facilitate prosthesis implantation. However, there are only a few reports in the literature addressing DVR in combination with aortic root enlargement. During AVR, surgeons aim to implant the largest possible prosthesis in order to optimize hemodynamic outcomes, reduce transvalvular gradients, promote left ventricular reverse remodelling, and minimize the risk of PPM. Nonetheless, implantation of an ideally sized prosthesis is often limited by the presence of a small aortic annulus. Various aortic root and annular enlargement techniques have therefore been described to address this challenge and avoid mismatch.

Aortic root enlargement in patients undergoing double valve replacement can be performed safely and facilitates the implantation of an appropriately sized mechanical or biological aortic valve prosthesis in patients with a small aortic annulus, thereby helping to avoid patient-prosthesis mismatch.