Updates on Y-Incision Aortic Annular Enlargement

This article is part of CTSNet’s Guest Editor Series, “Mastering Aortic Root Surgery—Learning From Top Surgeons”. Dr. Lorena Montes invited top cardiac surgeons from around the world to contribute clinical videos on various aortic root surgery techniques. 

The Y-Incision aortic annular enlargement (AAE) was developed in August 2020 (1) and there have been several modifications, including the placement of valve stitches, enlargement of proximal ascending aorta for future valve-in-valve (V-in-V) transcatheter aortic valve replacement (TAVR), and changes to the closure of the aortotomy. The author emphasizes the key points and pitfalls for this updated technique, which was discussed in more detail in the Annals of Cardiothoracic Surgery. (2)

The patient had severe aortic stenosis with heart failure symptoms. Peak and mean gradients across the aortic valve (AV) were 71 and 40 mmHg, respectively. A preoperative CT angiogram (CTA) showed a root of 34 mm, an ascending aorta of 39 mm, and severe longitudinal calcification of the ascending aorta. A median sternotomy was performed with aortic cannulation at the distal ascending and proximal arch. A complete transverse aortotomy was made approximately 2 cm above the sinotubular junction (STJ) anteriorly and 1 cm above the STJ posteriorly. The aortic root was dissected above the left and right atrium to the level of the dome of the left atrium and the nadir of the noncoronary sinus. The annulus was measured to be 23 mm. A standard Y-incision was made at the left –non-commissure, extending from the aortotomy into the aortomitral curtain, underneath and parallel to the aortic annulus to their respective nadirs, by partially cutting into the left and right fibrous trigones. A 2 x 3 inch (5 x 7.5 cm) rectangular-shaped Hemashield Dacron patch was trimmed to a width 5 mm greater than the distance between the two cusp nadirs on each end.  

This patch was sewn to the aortomitral curtain and mitral annulus from the left fibrous trigone to the right fibrous trigone with a running 4-0 Prolene suture. The suture line was transitioned to the aortic annulus at the nadir of both the left and noncoronary sinuses, sutured along the longitudinal length of the patch to the level of the transverse aortotomy incision, and secured with additional 4-0 Prolene sutures. The valve sizer was placed in the enlarged root, touching all three nadirs of the aortic annulus to determine the size of the prosthesis, which was found to be size 29.  

The height of the divided left noncommissure was marked on the patch to indicate where the highest suture should be placed, and the size 29 valve sizer was then traced onto the patch. While the patch was pulled upward, the size 29 bioprosthetic valve was placed into the enlarged aortic root with one strut facing the left-right commissure to confirm that the marking of the valve sutures on the patch matched the sewing ring of the bioprosthesis, and the two coronary ostia were not obstructed.  

Nonpledgeted 2-0 Ethibond sutures were then placed along the native aortic annulus in a noneverting fashion. The size 29 valve was placed with one strut facing the left-right commissure, and the valve sutures were divided by three and evenly distributed to the sewing ring of the three cusps of the bioprosthetic valve, starting at the left-right commissure. The sutures at the nadirs of the noncoronary and left coronary sinuses, the lowest point of the aortic annulus, were tied first. A longitudinal aortotomy was made in the posterior proximal ascending aorta, and the distal end of the rectangular patch was trimmed in a triangular shape symmetrically, with the tip of the triangle 2-3 cm above the strut. The aortotomy was closed with 4-0 Prolene, incorporating the triangular-shaped end of the patch into the longitudinal aortotomy using the “Roof” technique (3). 

The post-cardiopulmonary bypass mean gradient across the AV was 6 mmHg. The patient was discharged without blood transfusion or complications. At the three-month follow-up, the mean gradient across the AV was 5 mmHg and the left ventricular outflow tract was 2 mmHg. CTA showed that the aortic root was 41 mm, STJ was 38 mm, and there was no pseudoaneurysm. 

References

1. Yang B. A novel simple technique to enlarge the aortic annulus by two valve sizes. JTCVS Tech 2021;5:13-16.
2. Yang B, Monaghan K, Hassler K, Brescia A, Yazdchi F. Updates on Y-incision aortic annular enlargement. Ann Cardiothorac Surg. 2024 May 31;13(3):308-310. doi: 10.21037/acs-2023-aae-0140. Epub 2024 Apr 25. PMID: 38841090; PMCID: PMC11148758.
3. Yang B, Naeem A, Palmer S. "Roof" technique-a modified aortotomy closure in Y-incision aortic root enlargement upsizing 3-4 valve sizes. JTCVS Tech 2022;12:33-36.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.