Changes in Aortic Root Dimensions Post Aortic Root Enlargement with Y-incision and Modified Aortotomy

Purpose: Lifetime management in aortic stenosis can be facilitated by aortic root enlargement (ARE) to improve anatomy for future valve-in-valve procedures. A mitral valve-sparing ARE technique (“Y-incision”) and sinotubular junction (STJ) enlargement (“Roof” patch aortotomy) allow upsizing by 3-4 valve sizes, but quantitative analysis of changes in root anatomy is lacking.

Methods: Among 51 patients who underwent ARE by Y-incision technique at our center (± proximal ascending enlargement using Roof technique) we identified 17 patients with high-quality pre-operative and post-operative CT angiography (CTA) scans to allow quantitative analysis of analysis of aortic root dimensions. Detailed measurements of the annulus/basilar ring and sinuses (sinus widths & heights, coronary heights, STJ diameter & area, valve-to-coronary distances) were performed by an expert cardiovascular imager on both pre- and post-operative CTAs. The basal ring was defined as the functional annular plane/size when a bioprosthetic valve was present.

Results: Average age was 67 ± 8 years, the majority were female (13, 77%), and 4 (24%) had undergone prior AVR. Valve upsizing was 3 sizes in 13 (77%) and 4 sizes in 4 (23%). Post-op mean basal ring diameter was similar in size to the native annular diameter (25.9 vs. 24.9 mm), but significantly bigger than prior prosthetic valve in redo AVR (24.6 vs. 18.0, p< 0.01). Diameters of the sinuses at pre-op CT [28.9 ± 3.6 (R), 30.3 ± 3.7 (L) and 30.7 ± 4.3 (N) mm] increased by +6.7 ± 2.4 (R), +6.4 ± 3.5 (L) and +6.3 ± 3.6 mm (N). Mean diameter of the STJ increased from 29.0 ± 4.4 mm pre-op to 35.6 ± 3.0 post-op (+5.2 ± 3.7 mm change), and the degree of enlargement with the Roof technique was slightly more than without Roof technique (+6.0 ± 0.4 mm vs. +4.9 ± 4.2 mm). Coronary artery height from the basal ring decreased by -5.2 ± 3.4 and -3.6 ± 2.4 mm respectively on post-op CT due to the supra-annular position of the valve, however, the post-operative valve-to-coronary artery distances were 6.1 ± 1.6 mm (LM) and 4.2 ± 1.7 mm (RCA).

Conclusion: The Y-incision root enlargement technique significantly enlarges the sinus and STJ diameters by 5-6 mm while preserving favorable valve-to-coronary distances despite upsizing by 3-4 valve sizes, resulting in post-operative anatomy that is favorable for future TAV-in-SAV.

Identify the source of the funding for this research project: None