Aortic Annular Enlargement with Y-Incision/Rectangular Patch: Tips and Pitfalls

The Y-incision/rectangular patch aortic annular enlargement (Y-incision AAE) was developed in August 2020 as a simple, reproducible, and effective approach for annular enlargement. The goal of the Y-incision AAE is to enlarge the crown-shaped surgical aortic annulus and root to accommodate a larger valve with an orifice that matches the diameter of the patient's basal ring. A complete or partial transverse aortotomy is performed 2.0 cm above the sinotubular junction anteriorly. A Y-incision is made through the left-non commissure onto the aortomitral curtain, extending underneath the crown-shaped surgical aortic annulus into the left and right fibrous trigones. A rectangular patch is sewn to the aortomitral curtain from trigone to trigone, and aortic annulus on both sides. A valve sizer touches all 3 nadirs of the aortic annulus to size the prosthesis. Nonpledgetted 2-0 Ethibond valve sutures are placed in a noneverting fashion. The valve sutures are divided by 3 and distributed evenly to each cusp of the sewing ring after aligning 1 valve strut at the left-right commissure. After the prosthesis is tied down, A 2-3 cm longitudinal aortotomy is performed in the posterior side of the proximal ascending aorta. The patch is trimmed to a triangular shape at distal end and incorporated into the longitudinal aortotomy for the aortic closure while enlarging the sinotubular junction and proximal ascending aorta. The simple and reproducible Y-incision AAE technique upsizes 3-4 valve sizes to achieve optimal hemodynamics and durability while also preparing patients for the next intervention in the lifetime management of aortic valve disease.