A “Y” Incision/Rectangular Patch to Enlarge the Aortic Annulus by 4 Valve Sizes in TAV and BAV Patients

We previously described using a “Y” incision and rectangular patch to enlarge the aortic annulus by 2-3 valve sizes for aortic valve replacement (AVR) with bioprosthesis (1) or mechanical valve (2) in patients with trileaflet aortic valve (TAV). As we are becoming more experienced, we are able to enlarge the aortic annulus by 4 valve sizes routinely in either TAV or bicuspid aortic valve (BAV). In this video we used a case of TAV to introduce the standard method of a “Y” incision and rectangular patch, then we discussed the difference of using this technique in BAV patients.

The patient was a 64-year-old female with body weight of 97 kg (213 pounds), BMI of 39 kg/m2, and BSA of 1.9 m2. She had symptomatic severe aortic stenosis with peak gradient of 98 mmHg and mean gradient of 59 mmHg, and sick sinus syndrome. She was not a candidate for transcatheter AVR (TAVR) due to her small aortic root (27 mm) and low coronary ostia. The aortic annulus size was measured at 19 mm after the calcified AV was resected. After root enlargement with the “Y” incision, we placed a 27 Magna Ease valve (Edwards Life Sciences; Irvine, CA). Post-operative aortic valve mean gradient was 5 mmHg and peak gradient was 11 mmHg with normal coronary blood flow, no mitral regurgitation, and no blood transfusion. This patient was discharged on post-operative day 4 without complications.

Operative steps
1. After the heart was arrested, a partial transverse aortotomy was made 1.5 cm above the sinotubular junction, stopping right above the left-non commissure post.
2. The scarred aortic valve was excised and the annulus was debrided. The annulus was sized to be 19 mm.
3. The left-non commissure post was incised from the aortotomy into the aorto-mitral curtain.
4. The incision was extended in a “Y” fashion undermining the left and noncoronary annulus to their respective nadir, but not reaching the muscular portion on the left or the membranous septum on the right. The tissue underneath the nadirs, the left and right fibrous trigone, is strong fibrous tissue. We use that tissue to anchor the patch.
5. A rectangular shaped Hemashield Dacron patch was trimmed in width slightly longer than the distance between the two cusp nadirs. This patch was sewn to the aorto-mitral curtain/mitral annulus from left to right fibrous trigone with running 4-0 Prolene suture. The suture line was transitioned to the undermined aortic annulus at the nadir of both left and noncoronary sinuses, sutured along the longitudinal length of the patch up to the level of the transverse aortotomy incision and secured.
6. The upsized Magna Ease valve sizer was placed in the enlarged root touching three nadirs of the aortic annulus and the position of the sizer on the patch was marked to guide the placement of valve sutures.
7. The non-pledgetted 2-0 Ethibond sutures were placed along the native aortic annulus in a noneverting fashion started from the right coronary sinus side and from outside in on the patch.
8. The bioprosthesis was placed with one strut facing the left-right commissural post, and all the valve stitches were passed through the sewing ring.
9. The sutures at nadirs of noncoronary and left coronary sinuses, which were the lowest points of the aortic annulus, were tied first to seat the valve well and prevent paravalvular leak. A portion of the patch lay beneath the prosthetic valve thereby enlarging the root and left ventricular outflow tract.
10. The aortotomy was then closed first by sewing the aorta to the left side of the patch almost to the mid part of the aortotomy, then from the pulmonary artery side to close the native aorta to aorta and tie to the suture closing the left side of the patch. The patch was trimmed and the right side of the patch and aorta was closed.

Tips and pitfalls: The “Y” incision should go through the left-non commissure post into the aorto-mitral curtain and be underneath aortic annulus. By doing so, we were able to sew the patch to the aortic annulus on both sides, which was very secure and would be re-enforced by the valve stitches. The “Y” incision should be as far as possible to extensively enlarge the root to 4 valve sizes, but not reach the muscular septum next to the nadir of left coronary annulus and membranous septum next to the non-coronary annulus. In the redo AVR, when the aorto-mitral curtain is destroyed from removing the old prosthesis, it is critical to identify the aortic annulus before making the “Y” incision. The patch should be slightly wider than the distance between the nadirs of left and non-coronary sinus. The valve stitches on the patch should not be higher than the split left-non commissure post. When closing the aortotomy, it is important for the surgeon to enlarge the sino-tu bular junction and proximal ascending aorta to prepare patients for future transcatheter AVR. When the left coronary ostium arises high, the surgeon can upsize the valve more, by as much as 4 valve sizes. If the left coronary ostium arises low and close to the annulus, surgeon could only upsize by 3 valve sizes to avoid obstruction of the left coronary ostium.

The structure of the aortic root in patients with BAV is a little different. The left-non commissure post is located more towards to the left coronary sinus and close to the left coronary ostium. As a result, the incision of aorto-mitral curtain underneath the left coronary sinus was much shorter than that underneath the non-coronary sinus. The patching was very similar after the “Y” incision in patients with BAV. (Second case)

Since the “Y” incision was above the mitral annulus and left atrium, this technique only enlarged the aortic annulus and aortic root but not left ventricular outflow tract. As a result, it also did not affect the mitral valve function either. This technique enlarged the aortic annulus and root posteriorly and the patch was expanded into the transverse sinus. We have not seen distortion of the left coronary arteries on TEE or post-operative CTA, or injury of conducting system, in both TAV and BAV patients.

References

1. Yang, B. A Novel Simple Technique to Enlarge the Aortic Annulus by Two Valve Sizes. JTCVS Tech. 2021 Feb;5:13-16. Doi: 10.1016/j.xjtc2020.10.038. Epub 2020 Nov 5.
2. Yang B, Naeem A. A “Y” Incision/Rectangular Patch to Enlarge the Aortic Annulus by 3 Valve Sizes”. Annals of thoracic surgery. In Press.

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