Y-incision aortic annular enlargement using the arc patch modification: a step-by-step tutorial

Aortic annular enlargement is an important adjunct to aortic valve replacement in patients with a small aortic annulus and restricted aortic root anatomy. The Y-incision technique facilitates implantation of a larger prosthetic valve, reducing the risk of prosthesis-patient mismatch and improving postoperative haemodynamics. This video tutorial demonstrates Y-incision aortic annular enlargement combined with bioprosthetic aortic valve replacement in a 67-year-old woman with symptomatic severe aortic stenosis and a severely restricted aortic root anatomy. Preoperative imaging revealed a 19 mm aortic annulus, small aortic root dimensions and a narrow sinotubular junction. Following extensive aortic root mobilization, a Y-shaped incision was extended through the aortomitral curtain and reconstructed using an arc-shaped patch modification to facilitate annular, root and sinotubular junction enlargement. The enlarged annulus allowed implantation of a 23 mm bioprosthetic valve with careful commissural alignment and root reconstruction. Postoperative imaging demonstrated excellent valve position and function without paravalvular leak. Peak and mean transvalvular gradients were 14 and 8 mmHg at discharge, and remained stable at 4-month follow-up. This video tutorial highlights the key technical steps of Y-incision aortic annular enlargement and demonstrates excellent early haemodynamic results following implantation of an appropriately sized prosthesis.