Comparison of the short-term outcomes between Y-incision aortic annular enlargement and traditional aortic annular enlargement techniques

Abstract

Background: The short-term efficacy and safety of the Y-incision technique of aortic annular enlargement (AAE) has been established. We aimed to determine how the short-term outcomes of the Y-incision technique compared to traditional AAE techniques.

Methods: From February 2011 to June 2022, 380 patients at the University of Michigan Hospital underwent aortic valve replacement (AVR) with AAE using either traditional annular enlargement techniques (Traditional group, n=270), including Nicks [63% (171/270)], Manouguian [34% (91/270)], and others [3% (8/270)], or the Y-incision technique (Y-incision group, n=110). Propensity score matching was performed by controlling for age, sex, body surface area (BSA), hypertension, diabetes, dialysis, chronic lung disease, stroke, prior cardiac surgery, primary indication, operative status, concomitant procedures, and prosthesis type, to generate a balanced cohort of 103 pairs.

Results: There were no differences in demographics, comorbidities, primary indications of the operations, or concomitant procedures between the matched groups. The median native aortic annulus diameter, measured in the operating room, was 21 mm for both groups. Median prosthesis size was 23 in the Traditional group, and 27 in the Y-incision group (P<0.001). There were no differences in perioperative complications/outcomes between the matched groups, including operative mortality, which was 3.9% (8/206) overall. Short-term survival was similar between the groups on Kaplan-Meier analysis; one-year survival was 95% in the Traditional group, and 97% in the Y-incision group (P=0.54). The Y-incision group had significantly lower mean aortic valve gradients (7 vs. 10 mmHg, P<0.001), larger aortic valve areas (2.2 vs. 1.8 cm², P=0.007), and less moderate/severe patient-prosthesis mismatch (PPM) (5.5% vs. 23%, P=0.039) on one-year follow-up echocardiography.

Conclusions: The Y-incision technique was as safe and more effective in enlarging the aortic annulus and upsizing the prosthetic valve than the traditional techniques of AAE in AVR for small aortic annuli.

Keywords: Aortic annular enlargement (AAE); Manouguian; Nicks; Y-incision; aortic root enlargement.

Figure 1

Standardized mean differences of the propensity score-matched population. Standardized mean differences less than 0.1 indicate acceptable balance of the covariates between the matched groups. CABG, coronary artery bypass grafting.

Figure 2

Kaplan-Meier estimation of early survival between the Traditional and Y-incision aortic annular enlargement groups. Survival at one year was 95% (95% CI: 89%, 98%) in the traditional group compared to 97% (95% CI: 90%, 99%) in the Y-incision group (P=0.54). AAE, aortic annular enlargement; CI, confidence interval.