Changes in aortic root dimensions post aortic root enlargement with Y-incision and modified aortotomy

Abstract

Background: Lifetime management in aortic stenosis (AS) can be facilitated by aortic root enlargement (ARE) to improve anatomy for future valve-in-valve (ViV) procedures. A mitral valve-sparing ARE technique ("Y-incision") and sinotubular junction (STJ) enlargement ("roof" patch aortotomy) allow upsizing by 3-4 valve sizes, but quantitative analysis of changes in root anatomy is lacking.

Methods: Among 78 patients who underwent ARE by Y-incision technique (± roof aortotomy closure) we identified 45 patients with high-quality pre- and post-operative computed tomography angiography (CTA) scans to allow analysis of change in aortic root dimensions. Detailed measurements of the annulus/basilar ring and sinuses were performed by an expert imager on both pre- and post-operative CTAs. The basal ring was defined as the functional annulus when a bioprosthetic valve was present.

Results: Average age was 65±11 years, the majority were female (29, 64%), and 9 (20%) had undergone prior aortic valve replacement (AVR). Valve upsizing was ≥3 sizes in 41 (91%). Post-operative mean basal ring diameter was larger compared to the native annular diameter (26.3 vs. 25.3 mm, P<0.01) and substantially larger than prior prosthetic valve in redo AVR (25.6 vs. 19.3 mm, P<0.001). Diameters of the sinuses at pre-operative computed tomography (CT) increased by +7.7±2.8 [right sinuses of Valsalva (R SVS)], +6.7±3.0 [left sinuses of Valsalva (L SVS)], and +6.6±2.9 mm [non-coronary sinuses of Valsalva (N SVS)]. Mean diameter of the STJ increased to 38.3±3.7 post-operative (+8.1±3.2 mm). Left main (LM) and right coronary artery (RCA) heights decreased by -6.3±3.3 and -3.7±3.4 mm respectively due to the supra-annular position of the valve, however, the post-operative valve-to-coronary (VTC) artery distances were 6.6±2.3 and 4.9±2.0 mm, respectively.

Conclusion: The Y-incision root enlargement technique significantly enlarges the sinus and STJ diameters by 6-7 mm while preserving VTC distances despite upsizing by 3-4 valve sizes, resulting in post-operative anatomy that is favorable for future transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV).

Keywords: Aortic root enlargement (ARE); Y-incision; aortic valve replacement (AVR); roof procedure; valve-in-valve (ViV).

Figure 1

Detailed aortic root measurement schematic. Standard root measurements for transcatheter valve replacement planning were performed on pre-operative CT scans including annular sizes, sinus of Valsalva dimensions, heights of the sinuses and coronary ostia, and STJ size (A). On post-operative CT scans after bioAVR with upsizing and ARE, the pre-operative measurements were repeated, with the addition of measurements of the VTC and VTA distances (B). STJ, sinotubular junction; RCA, right coronary artery; LM, left main; CT, computed tomography; bioAVR, bioprosthetic aortic valve replacement; ARE, aortic root enlargement; VTC, valve-to-coronary; VTA, valve-to-aorta.

Figure 2

Representative example with 3D renderings of the aortic root from pre-operative (left) and post-operative (right) CT scans, demonstrating typical changes in the anatomy observed with Y-incision ARE, including significant enlargement of the sinus widths (+11 mm in this case) and STJ with upsizing by three valve sizes (implanted 29 mm Maga Ease). RCA, right coronary artery; LM, left main; 3D, three-dimensional; CT, computed tomography; ARE, aortic root enlargement; STJ, sinotubular junction.