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

Abstract

Background: Trials comparing transcatheter aortic valve replacement and surgical aortic valve replacement (SAVR) have shown that in patients with annuli <26 mm, SAVR had negative hemodynamic and clinical outcomes. Recently, studies revealed that the effective orifice diameter of surgical prosthetic valves is 5-7 mm smaller than the labeled valve size. To improve outcomes of SAVR, the Y-incision aortic annular enlargement (AAE) enlarges the surgical aortic annulus to accommodate a prosthetic valve 3-4 sizes larger with an effective orifice area that matches the patient's native annulus. This review discusses when and how the Y-incision AAE should be performed.

Methods: OVID MEDLINE, OVID Embase, and Cochrane Library were searched with terms that included "Y-incision aortic annular enlargement," "valve sizes," and "long-term survival." The search included publications after 2020. The reference lists of included studies were reviewed to retrieve additional studies.

Results: In patients with matched native annular sizes, AAE significantly improved midterm survival without increasing perioperative complications. Patients treated with a larger valve had notably better long-term survival and small valve sizes were significant risk factors for operative and long-term mortality. Compared with patients treated with a Nicks or Manougian procedure, the hemodynamics in patients treated with Y-incision AAE were significantly better.

Conclusions: Y-incision AAE could be routinely considered for patients with a normal annulus (17-25 mm) undergoing SAVR.