Aortic Valve Replacement with Aortic Annulus Enlargement Using the L-Incision Procedure for Aortic Stenosis with Calcification of the Narrow Aortic Annulus

Abstract

Aortic annulus enlargement is a procedure often performed to prevent prosthesis-patient mismatch. This report describes the procedure that allowed us to achieve adequate annulus enlargement in a case enlargement with the conventional Nicks procedure was difficult. The patient was a 70-year-old woman who underwent aortic valve replacement along with aortic annulus enlargement, for severe aortic valve stenosis. The conventional Nicks procedure was not performed due to calcification of the non-coronary sinus of Valsalva and the aortic valve commissure between the left coronary cusp and the non-coronary cusp. We decided to incise the non-coronary sinus of Valsalva from 2 mm lateral to the left coronary-non-coronary commissure. Although the cut line was extended across the aortic annulus into the aorto-mitral curtain, the aortic annulus and anterior mitral leaflet were not far enough apart for adequate enlargement. We therefore decided to add a horizontal incision line toward the right fibrous trigone and create an L-shaped incision line. As a result, the aortic annulus was dilated 10 mm and a 21 mm Inspiris prosthesis (Edwards Lifesciences, Irvine, CA, USA) was successfully implanted in the supra-annular position. The postoperative course was uneventful and the patient was discharged on postoperative day 16 in an ambulatory condition. The postoperative echocardiogram showed no prosthesis-patient mismatch or perivalvular leakage.An L-incision may be one of the options to enlarge the aortic annulus in cases where the conventional Nicks procedure is difficult to perform.