Y Incision and Roof Technique for Aortic Root Enlargement: A Minimally Invasive Approach

The Y incision and roof technique for aortic valve replacement enable implantation of a large prosthetic valve and extensive enlargement of the sinotubular junction. Surgeons have been reluctant to adopt a minimally invasive approach for this procedure because of its complexity and risk. The Stonehenge technique was designed to achieve an ideal surgical view of the aortic root through a small right thoracotomy. Herein, we report implementing a Y incision and roof technique for aortic valve replacement through a minimally invasive approach facilitated by the Stonehenge technique. The Y incision and roof technique for aortic valve replacement enable implantation of a large prosthetic valve and extensive enlargement of the sinotubular junction. Surgeons have been reluctant to adopt a minimally invasive approach for this procedure because of its complexity and risk. The Stonehenge technique was designed to achieve an ideal surgical view of the aortic root through a small right thoracotomy. Herein, we report implementing a Y incision and roof technique for aortic valve replacement through a minimally invasive approach facilitated by the Stonehenge technique. Techniques for aortic root enlargement during aortic valve replacement (AVR) have recently gained more importance in patients with small aortic annuli as a component of lifetime management of reinterventions, including valve-in-valve transcatheter AVR (VIV-TAVR).1Sá M.P. Ramlawi B. Sicouri S. et al.Lifetime management of aortic valve disease: aligning surgical and transcatheter armamentarium to set the tone for the present and the future.J Card Surg. 2022; 37: 205-213Crossref PubMed Scopus (16) Google Scholar The Y incision technique, first reported by Bo Yang, enables implantation of valves 3 to 4 sizes larger than the native annulus.2Yang B. A novel simple technique to enlarge the aortic annulus by two valve sizes.JTCVS Tech. 2021; 5: 13-16Abstract Full Text Full Text PDF PubMed Google Scholar In addition, the roof technique facilitates enlargement of the sinotubular junction (STJ), providing a favorable platform for future VIV-TAVR.3Yang B. Naeem A. Palmer S. "Roof" technique—a modified aortotomy closure in Y-incision aortic root enlargement upsizing 3-4 valve sizes.JTCVS Tech. 2022; 12: 33-36Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar However, surgeons have been reluctant to adopt a minimally invasive approach for this procedure because of its complexity. The Stonehenge technique of Yamazaki and colleagues4Yamazaki M. Yoshitake A. Takahashi T. et al.Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy.Gen Thorac Cardiovasc Surg. 2018; 66: 700-706Crossref PubMed Scopus (6) Google Scholar achieves an ideal surgical view of the aortic root through a small right thoracotomy. Herein, we report implementation of the Y incision and roof technique in AVR through a right infra-axillary thoracotomy using the Stonehenge technique. A 6- to 7-cm skin incision is made along the edge of the pectoralis major muscle in the right anterior axillary line, and a thoracotomy is performed through the third or fourth intercostal space. Cardiopulmonary bypass is established through the right femoral artery and vein. By placement of several retraction stitches on the pericardium as described for the Stonehenge technique, the aortic root is approximated toward the chest wall (Figure 1).4Yamazaki M. Yoshitake A. Takahashi T. et al.Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy.Gen Thorac Cardiovasc Surg. 2018; 66: 700-706Crossref PubMed Scopus (6) Google Scholar After aortic cross-clamping and antegrade cardioplegia, a two-thirds circumferential transverse incision is made in the ascending aorta 1 cm superior to the STJ (Figure 2A). After resection of the leaflets and débridement of the aortic annulus, the right end of the aortotomy is extended by splitting the commissure post between the left and noncoronary cusps and extending along the annulus to the nadir of the left and noncoronary cusps (Figure 2B; Y incision technique).2Yang B. A novel simple technique to enlarge the aortic annulus by two valve sizes.JTCVS Tech. 2021; 5: 13-16Abstract Full Text Full Text PDF PubMed Google Scholar A rectangular patch (autopericardium or Hemashield [Maquet]) is trimmed to match the distance between the 2 coronary cusp nadirs. Running 4-0 polypropylene (Prolene; Ethicon) is used to stitch the patch to the aortomitral curtain and Valsalva sinus along the Y incision (Figure 2C). After sizing of the aortic annulus, a prosthetic valve is fixed in an intra-annular position with pledgeted 2-0 polyethylene terephthalate sutures (Ethibond; Ethicon) on the patch and single interrupted 2-0 sutures on the native aortic annulus (Figure 2D). The distal part of the patch is trimmed into a triangle shape (Figure 3A). The ascending aorta is incised longitudinally 3 cm from the right end of the aortotomy, which is then closed by fitting the triangular part of the patch to the longitudinal aortotomy with running 4-0 Prolene sutures (Figure 3B; roof technique)3Yang B. Naeem A. Palmer S. "Roof" technique—a modified aortotomy closure in Y-incision aortic root enlargement upsizing 3-4 valve sizes.JTCVS Tech. 2022; 12: 33-36Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar (Video).Figure 2Intraoperative photographs. (A) Two-thirds circumferential transverse incision in the ascending aorta. (B) Y incision into the aortic annulus. (C) The trimmed autopericardium is sutured along the Y incision. (D) Annulus sutures are placed in a single interrupted fashion, and pledgeted mattress sutures are placed from outside the pericardial patch (along the blue line on the patch).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3(A) After valve implantation, the patch is trimmed into a triangle shape along the blue line on the patch. (B) The aortotomy is closed by fitting the triangular part of the patch to the longitudinal aortotomy (white lines).View Large Image Figure ViewerDownload Hi-res image Download (PPT) We have performed AVR by the Y incision and roof technique through a right mini-thoracotomy using the Stonehenge technique in 3 women aged 63 to 74 years, 1 of whom underwent concomitant septal myectomy. The preoperative aortic annulus was 17 mm in 1 patient and 19 mm in the other 2 patients. All 3 implanted prostheses were 23-mm Inspiris Resilia aortic valves (Edwards Lifesciences LLC). A Dacron patch was used in 2 patients and autopericardium in 1 patient. The cardiopulmonary bypass and aortic cross-clamp times were 224 and 149 minutes and 201 and 144 minutes, respectively, in 2 cases, and 224 and 166 minutes in the patient requiring septal myectomy. Since the advent of TAVR, management strategies for aortic stenosis have changed considerably,1Sá M.P. Ramlawi B. Sicouri S. et al.Lifetime management of aortic valve disease: aligning surgical and transcatheter armamentarium to set the tone for the present and the future.J Card Surg. 2022; 37: 205-213Crossref PubMed Scopus (16) Google Scholar and as VIV-TAVR has attracted more attention, surgical interventions for aortic root enlargement have regained momentum.5Hawkins R.B. Beller J.P. Mehaffey J.H. et al.Incremental risk of annular enlargement: a multi-institutional cohort study.Ann Thorac Surg. 2019; 108: 1752-1759Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Implanting a larger bioprosthetic valve eliminates the risks of immediate prosthesis-patient mismatch and early valve deterioration and facilitates successful future VIV-TAVR. There are several maneuvers for enlarging the aortic root with patch augmentation. The procedures of Nicks and colleagues6Nicks R. Cartmill T. Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement.Thorax. 1970; 25: 339-346Crossref PubMed Scopus (239) Google Scholar and Manougian and Seybold-Epting7Manouguian S. Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique.J Thorac Cardiovasc Surg. 1979; 78: 402-412Abstract Full Text PDF PubMed Google Scholar enlarge the posterior aortic ring by extending the aortic incision into the anterior mitral leaflet. Although these procedures are relatively simple and widely accepted, the extent of enlargement of the aortic annulus and STJ is limited. The Konno procedure enlarges the anterior aortic ring extensively by incising the aortic annulus, right ventricle, and ventricular septum.8Konno S. Imai Y. Iida Y. Nakajima M. Tatsuno K. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring.J Thorac Cardiovasc Surg. 1975; 70: 909-917Abstract Full Text PDF PubMed Google Scholar However, the complexity and extensiveness of the right thoracotomy approach make it appear challenging. The Y incision and roof technique enable remarkable expansion of the aortic root components, including the aortic annulus, Valsalva sinus, and proximal ascending aorta.3Yang B. Naeem A. Palmer S. "Roof" technique—a modified aortotomy closure in Y-incision aortic root enlargement upsizing 3-4 valve sizes.JTCVS Tech. 2022; 12: 33-36Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar These procedures are so complex that exposure of the aortic root is of utmost importance. The challenge, which has not yet been met to our knowledge, has been to devise a minimally invasive means of performing this innovative procedure. The Stonehenge technique entails shifting the whole heart by pulling it with pericardial retraction stitches toward the right chest wall, thus making surgical procedures through a right infra-axillary thoracotomy as easy and safe as through median sternotomy.4Yamazaki M. Yoshitake A. Takahashi T. et al.Stonehenge technique is associated with faster aortic clamp time in group of minimally invasive aortic valve replacement via right infra-axillary thoracotomy.Gen Thorac Cardiovasc Surg. 2018; 66: 700-706Crossref PubMed Scopus (6) Google Scholar The benefits of this technique are the following: a typical AVR can be performed without use of special minimally invasive surgery instruments; it provides a good, inverted cone–shaped surgical view, allowing intermittent lung inflation during the procedure; and use of a soft wound protector decreases the thickness of the chest wall and reduces the distance from the wound to the aortic root. All 3 of our procedures were completed within reach of the fingers without assistance of long-shafted surgical instruments or knot pushers and without videoscopic assistance. These factors may encourage surgeons to take up the challenge of performing these novel techniques through a minimally invasive approach in patients with small aortic annuli. In conclusion, we have performed Y incision and roof techniques for AVR through right infra-axillary thoracotomies. These procedures can be performed successfully by the Stonehenge technique. This less invasive approach may encourage patients with borderline indications for transcatheter procedures to accept surgical options. The Video can be viewed in the online version of this article [https://doi.org/10.1016/j.atssr.2023.05.007] on http://www.annalsthoracicsurgery.org. The authors wish to thank Dr Trish Reynolds, MBBS, FRACP, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. The authors have no funding sources to disclose.