Surgical Aortic Annulus Enlargement Using a Balloon Technique

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Aortic valve prostheses always result in some degree of transvalvular gradient. With the increasing use of bioprostheses in younger patients, a new concern has arisen in index surgery, implanting the largest possible prosthesis. 
 
When the risk of mismatch is anticipated, aortic annular enlargement (AAE) techniques are indicated, but are rarely used due to concerns about prolonged surgical times and an increased risk of bleeding. On average, the most commonly used techniques (1,2) add only one number, while Yang's technique adds three numbers. Most surgeons consider it too expensive to implant a prosthesis that is only one size larger.  
 
The Surgery 

Through an upper hemisternotomy, cardiopulmonary bypass (CPB) was initiated with direct cannulation. The aortic cross-clamp was applied and cardioplegia was administered. An aortotomy was then performed. 

After resection of the cusps, careful debridement and complete decalcification was performed. It is essential to avoid excessive decalcification, as it could result in annular defect. The first three stitches were placed in the commissures and the prosthesis was measured. 

To ensure accurate sizing, the sizer must fit comfortably with some resistance. A larger balloon catheter and prosthesis were then selected. For example, if the appropriate size is 23, a 25 balloon and a 25 prosthesis are chosen. Additional sutures were placed around the annulus using a non-everting mattress technique. 

Once the balloon was positioned inside the annulus, the inflation device was attached to the proximal end, and saline was inflated up to the nominal pressure (4 ATM), which was then carefully increased to the rated burst pressure (6 ATM). The system was locked and held until the prosthesis was ready. 

With the balloon inflated, all sutures were passed around the prosthetic ring. Immediately before lowering the prosthesis into place, the balloon was deflated and removed. The prosthesis was then tied to the annulus, and the aortotomy was closed in the usual manner.  
 
Tips and Pitfalls 

Several surgical strategies are used to optimize the annulus, including complete decalcification, supra-annular implantation, non-use of the pledget, and aortic annular enlargement (AAE). 

The tissue annulus diameter is measured intraoperatively using the cylindrical sizer supplied by the manufacturer. This is used to determine the size of balloon to be selected to enlarge the annulus at least one or two sizes larger and the corresponding prosthetic valve. 

The nominal pressure is the pressure in atmospheres required to inflate the balloon to its labeled diameter. To ensure that the selected diameter is achieved, it is very important to inflate the balloon until it reaches the rated burst pressure—the pressure that 99.9 percent of balloons can resist with 95 percent confidence without rupturing or damaging the vessel. 

Surgical enlargement of the aortic annulus with a balloon catheter is a simple technique that combines the knowledge and experience of both TAVR and SAVR. This method allows for the implantation of a larger prosthesis without increasing surgical times or the risk of bleeding. 

It is relatively low-cost, especially considering the benefits of lower transvalvular gradients and the facility of implanting a transcatheter valve in the future. 

References

1. Grubb KJ. Aortic Root Enlargement During Aortic Valve Replacement: Nicks and Manouguian Techniques. Operative Techniques in Thoracic and Cardiovascular Surgery 2015;20:206-18.
2. Deeb GM. The perfect prosthesis/patient match: pursuit of the Holy Grail. Ann Cardiothorac Surg 2024;13(3):224-235. doi: 10.21037/acs-2023-aae-0181
3. Tanaka D, Vervoort D, Mazine A, Elfaki L, Chung JCY, Friedrich JO, Ouzounian M. Early and mid-term outcomes of aortic annular enlargement: a systematic review and meta-analysis. Ann Cardiothorac Surg 2024;13(3):187-205. doi: 10.21037/acs-2024-aae-0023
4. Sá MPBO, Zhigalov K, Cavalcanti LRP, et al. Impact of Aortic Annulus Enlargement on the Outcomes of Aortic Valve Replacement: A Meta-analysis. Semin Thorac Cardiovasc Surg 2021;33:316-25
5. Errico KN, Hui DS. The role of aortic annular enlargement in the lifetime management of aortic stenosis patients. Ann Cardiothorac Surg 2024;13(3):291-293. doi: 10.21037/acs-2023-aae-0156
6. Pibarot P, Simonato M, Barbanti M, et al. Impact of Pre-Existing Prosthesis-Patient Mismatch on Survival Following Aortic Valve-in-Valve Procedures. JACC Cardiovasc Interv 2018;11:133-41.
7. Yang B, Ghita C, Makkinejad A, et al. Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes. J Thorac Cardiovasc Surg 2024;167:1196-1205.e2.
8. Yamashita K, Shimamura K, et al. Three-step surgical management algorithm for annular rupture in transcatheter aortic valve replacement. J Thorac Cardiovasc Surg Tech 2023;22:169-77.
9. Carroll JD, Mack MJ, Vemulapalli S, et al. STS-ACC TVT Registry of Transcatheter Aortic Valve Replacement. Ann Thorac Surg. 2021;111:701-722.
10. Durko AP, Head SJ, Pibarot P, Atluri P, Bapat V, Cameron DE, et al. Characteristics of surgical prosthetic heart valves and problems around labelling: a document from the European Association for Cardio-Thoracic Surgery (EACTS)—The Society of Thoracic Surgeons (STS)—American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. J Thorac Cardiovasc Surg. 2019;158:1041-54.
11. Tyszka AL, Jorge AJ, El Ghoz H. Dealing With the Aortic Annulus: Surgical Aortic Annulus Enlargement With a Balloon Catheter. Innovations. 2024;0(0). doi:10.1177/15569845241288550

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