Computed Tomography Analysis of Aortic Annular Enlargement During Surgical Aortic Valve Replacement

A 59-year-old woman with body surface area of 1.42 m², symptomatic severe aortic stenosis and low surgical risk was planned for surgical aortic valve replacement (SAVR). Preoperative computed tomography (CT) imaging revealed a calcified tricuspid aortic valve with an annulus area of 296 mm² during the diastolic phase. Respective coronary artery and sinotubular junction (STJ) heights from the aortic annulus were 13.8 mm and 18.6 mm in the left coronary artery (LCA), and 14.0 mm and 18.8 mm in the right coronary artery (RCA) (Figure A,B). The sinus of Valsalva (SOV) ranged from 24.4 to 26.8 mm, and the mean STJ diameter was 23.8 mm (Figure C,D). Intraoperative assessment by sizer indicated INSPIRIS RESILIA 19 mm (Edwards Lifesciences, CA, USA; external sewing ring diameter: 25 mm; profile height: 13 mm) was appropriately sized. The modified Nicks procedure was performed, taking the possibility of a future valve-in-valve procedure into consideration. This technique involved extending the aortotomy across the aortic annulus at the commissure between the left coronary cusp and the noncoronary cusp, enabling patch enlargement (patch width: 2 cm) of the aortic annulus to accommodate an upsizing to the INSPIRIS RESILIA 21 mm (external sewing ring diameter: 27 mm; profile height: 14 mm).

Figure.

Preoperative CT imaging of left and right coronary artery heights (A,B), SOV diameter (C), and STJ diameter (D). Postoperative computed tomography (CT) after aortic annular enlargement during SAVR shows the decreased coronary artery and STJ heights (E,F), and enlarged SOV and STJ (G,H) compared with preoperative CT. A future valve-in-valve TAVI would be safe despite the elevated position of the neoskirt relative to the coronary arteries (I,J: yellow arrows). Virtual distances of the valve to the coronary arteries and STJ (K,L) confirmed the low risk of coronary obstruction in a future valve-in-valve. SAVR, surgical aortic valve replacement; SOV, sinus of Valsalva; STJ, sinotubular junction; TAVI, transcatheter aortic valve implantation.

Postoperative CT images demonstrated decreased coronary artery and STJ heights compared with the preoperative measurements due to the supra-annular position (respective coronary and STJ heights: 8.5 mm and 13.6 mm in the LCA; 8.1 mm and 12.4 mm in the RCA) (Figure E,F). The risk of sinus sequestration during a future valve-in-valve procedure was considered to be low because of the enlargement of the SOV and STJ despite the elevated position of the neoskirt relative to the coronary arteries (Figure G–L).