Aortic root enlargement: When and how

Abstract

Aortic valve replacement is the definitive management for severe aortic stenosis. Intraoperatively, an aortic root enlargement (ARE) may be used to facilitate the implementation of a suitably sized prosthetic valve. This is to prevent patient prosthesis mismatch (PPM), a condition that causes a left ventricular outflow obstruction. There are four main techniques that are used to perform ARE, namely, Nicks, Manouguian, Nunez (modified Manouguian), and Kanno-Rastan procedures. They each involve incisions through different anatomical structures and allow a variety of valve sizes to be implanted. Studies prove that ARE effectively reduces the incidence of PPM. In addition, they show that there is no definitive link between ARE and perioperative mortality or other complications. There is a scarcity of literature exploring the comparative outcomes of each surgical technique. Therefore, further research is warranted for these procedures to be compared adequately. This review aims to summarise the available literature surrounding ARE with respect to three main questions. (1) What are the indications for ARE, (2) what surgical techniques exist to facilitate ARE, and (3) are there significant differences in patient outcomes when these surgical techniques are employed?

Aortic prosthetic size predictor in aortic valve replacement

“…However, not only does this practice add to operation time and complexity, but could also negatively affect morbidity and mortality in the field of minimally invasive surgical AVR, such as mini-thoracotomy and upper ministernotomy [ 12 ]. In addition, ARE is associated with several complications, such as mitral valve prolapse and aorto-left atrial fistula [ 13 ]. Therefore, recognizing the need for ARE and adequately determining a patient's risk of PPM are crucial prior to AVR.…”

Long-Term Results (up to 20 Years) of 19 mm or Smaller Prostheses in the Aortic Position. Does Size Matter? A Propensity-Matched Survival Analysis

“…Another option would be to perform aortic root enlargement [ 13 , 14 , 15 ]. Several techniques have been described [ 16 , 17 ] and they do not increase surgical risk in experienced hands [ 18 ]. Finally, rapid-deployment valves have been shown to perform well in the small aortic root [ 19 , 20 ] and they are a valid alternative to root enlargement in this population.…”

Updates on the Latest Surgical Approach of the Aortic Stenosis

“…Newly emerged data from expert centers require a refocusing on the Ross procedure, the potential benefits of this procedure and its place in the surgical tool box will be discussed in this review. Considering the possibility of V-in-V procedures, we will expose the potential long-term advantages of root enlargement during the initial surgery (Nicks, Nunez, Manouguian, Kono-Rastan) [7] and a new technique recently described: the Y incision with rectangular patch to enlarge the aortic annulus [8,9].…”

“…First described by Rahimtoola [62] in 1978, the technique was improved and, nowadays, we can resort to three posterior aortic root enlargement techniques (Manouguian, Nick and Nunez), as well as an anterior one, most frequently used in pediatric cardiac surgery (Konno-Rastan) [7]. In addition to these sometimes-old procedures, there is a recently published technique of rectangular patching after Y-cutting of the aortic root [8,9].…”