A modified surgical aortic root enlargement technique preserving the aorto-mitral curtain to prevent prosthesis-patient mismatch during aortic valve replacement

Introduction

Aortic valve disease (AVD) is the most prevalent heart valve disease worldwide (1). Severe AVD results in a significant decrease in quality of life and, if left untreated, is associated with a mortality rate of 50% within 3 years (2,3). The most common treatment modalities for AVD involve transcatheter interventions and cardiac surgery with replacement of the aortic valve with a prosthetic valve. Aortic valve replacement (AVR) is one of the most commonly performed cardiac surgical procedures and remains the definitive treatment for patients with severe AVD. There are currently two main categories available for selection of aortic prosthetic valves: bioprosthetic or mechanical prosthetic valves (4,5). The size of a prosthetic valve is based on the internal diameter of the aortic annulus, and the available sizes usually range from 19 to 29 mm. Prosthetic valve size must be carefully chosen to ensure that it provides an effective orifice area (EOA) sufficient to match the cardiac output requirements for a particular patient.

Prosthesis-patient mismatch (PPM) is a phenomenon that occurs when the EOA of a prosthetic valve is too small for a given patient’s body surface area (BSA) (6). The presence of PPM results in elevated transvalvular gradients through normal valves, which can impair left ventricular remodelling after AVR and increase mortality (7,8). The size of the aortic valve annulus is specific to each patient and may either be smaller than the smallest available prosthetic valve size or smaller than the required EOA to avoid PPM. In these cases, a surgical technique can be employed to increase the size of the aortic annulus or root and enable the implantation of a prosthetic valve that will avoid PPM without increasing operative risk (9).

There are many well-established surgical techniques that have been developed for aortic root enlargement (ARE) and/or annulus enlargement. Some of the most commonly used techniques are the Nicks procedure (10), the Manouguian procedure (11), and more recently the Y-incision/rectangular patch procedure developed by Dr. Bo Yang (12,13). The Nicks procedure involves extending the aortotomy incision posteriorly through the non-coronary sinus across the aortic annulus up to the origin of the mitral valve. A piece of a synthetic graft in the shape of what was originally described as a “tongue” is then sutured to the fibrous origin of the mitral annulus and continued along the aortic incision margins to enlarge both the aortic annulus and the proximal ascending aorta. In the Manouguian procedure, the aortotomy is extended posteriorly through the commissure of the left and non-coronary cusps and continued across the aortic annulus, through the aorto-mitral curtain, and into the anterior leaflet of the mitral valve. A fusiform shaped Dacron or pericardium patch is then sutured into the “V” shaped defect of the anterior mitral leaflet. For the Y-incision/rectangular patch procedure, an incision is made from the aortotomy through the commissure of the left and non-coronary cusps into the aorto-mitral curtain. The incision is then extended into a “Y” shape on the aorto-mitral curtain parallel to the aortic annulus up to the nadirs of the left and non-coronary cusps. A rectangular Dacron patch is then sutured into the aorto-mitral curtain. The incisions in both the Manouguian and Y-incision/rectangular patch methods are continued into the aorto-mitral curtain resulting in increased surgical complexity and increased operative risks. These three techniques enable enlargement of both the aortic root and the aortic annulus. Herein, we describe a modification of the Nicks procedure for ARE without altering the aortic annulus to accommodate a larger aortic valve prosthesis by replacing the non-coronary sinus while also maintaining the integrity of the aorto-mitral curtain in addition to the fibrous body. We present this article in accordance with the SUPER reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0006/rc).

Preoperative preparations and requirements

This technique was developed at the University of Ottawa Heart Institute (UOHI) in the cardiac surgery operating rooms. UOHI is a tertiary hospital specialized in cardiac disease medical and surgical management. The procedure requires a standard cardiac surgery operating room with standard cardiac surgery AVR instruments and materials, primary surgeon, surgical assistant, standard cardiac surgery anesthesiology team (anesthetist ± anesthesiology assistant), perfusionist, and nursing team.

A comprehensive preoperative assessment is essential to identify patients at risk for PPM and to plan ARE in a deliberate manner. In the illustrative clinical case (Video 1), transthoracic echocardiography confirmed severe aortic stenosis, with a mean transvalvular gradient of 42 mmHg, a peak gradient of 74 mmHg, and a calculated aortic valve area of 0.7 cm², consistent with advanced obstruction. Left ventricular systolic function was preserved. A coronary angiogram demonstrated no coronary artery disease.

Detailed anatomic characterization was obtained using contrast-enhanced cardiac computed tomography. Multiplanar reconstruction demonstrated a virtual basal ring (radiographic annulus) measuring 21 mm × 20 mm, with an annular perimeter of 73 mm and an annular area of 406 mm², confirming a small aortic annulus. The aortic root measured 28 mm × 27 mm, and the sinotubular junction measured 23 mm. Patient-specific anthropometric data further informed surgical planning. With a height of 160 cm and a weight of 94.6 kg, the patient’s BSA was calculated at 2.05 m² using the Mosteller formula (14). When indexed to this BSA, implantation of a bioprosthetic valve smaller than 23 mm would place the patient at significant risk for PPM based on known prosthesis hemodynamic profiles. ARE was therefore required to allow for the implementation of an adequately sized prosthetic valve. After shared decision-making regarding valve type, including discussion of the advantages and limitations of mechanical versus bioprosthetic valves, the patient elected to proceed with a tissue prosthesis. The technique proposed in this paper can be used with either a tissue prosthesis or a mechanical prosthesis to the same effect.

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this surgical technique and accompanying video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

The description of this technique is based on Feindel’s manuscript regarding root enlargement (15). This procedure represents a modification of the Nicks procedure originally described in 1970. This procedure required approximately 15 additional minutes of operative time compared to standard AVR. Video 1 portrays a clinical case in which this technique was applied. The video provides an overview of the clinical case with demographic data, diagnostic measurements and pre-operative imaging. This is followed by a live intra-operative case recording from the main surgeon’s point-of-view with a voice-over outlining the surgical steps and key consideration points. The video ends with intra-operative transesophageal echocardiography demonstrating the final result.

Exposure, conduit preparation, and setup

The patient was brought to the operating room and positioned supine on the operating table. The use of a shoulder roll (either with a rolled-up towel or specially manufactured cushion) can be considered to achieve a sternal plane level to the ground to facilitate exposure on a case-by-case basis. In our institution, the lead surgeon stands on the right side of the patient with the first and occasionally second assistant standing on the patient’s left side. Intra-operative monitoring was in accordance with the recognized standard for cardiac surgery and AVR with the use of transesophageal echocardiography, cerebral oxygen saturation, and other anesthetic monitors. After median sternotomy, the pericardium was opened in an inverted “T” fashion and suspended to the chest wall with interrupted sutures. The pericardial incision extends from the attachment of pericardium to ascending aorta superiorly to the level of the diaphragm inferiorly. Heparin was administrated. Standard aortic and right atrial cannulation was performed, and cardiopulmonary bypass (CPB) was initiated. A vent was then placed into the right pulmonary vein. The aorta was cross-clamped, and myocardial protection was achieved with antegrade (± retrograde) cardioplegia.

Aortotomy and native valve excision

A standard oblique aortotomy was created and carried down toward the mid portion of the non-coronary sinus, providing wide exposure of the valve and annulus. The native aortic valve was then excised, and annular debridement/decalcification was performed meticulously. At this stage, the annulus was sized with the intended prosthesis sizers.

Decision point: confirm the need for enlargement (planned vs. bailout)

If the annulus would not accommodate a prosthesis size required to avoid PPM, the enlargement technique is performed deliberately and early, rather than as a late “bailout” to maintain operative efficiency. This planned approach aligns with contemporary evidence supporting the safety of adding ARE to AVR (9).

Root enlargement

Root-enlargement incision

The aortotomy was extended further into the non-coronary sinus up to the aortic annulus just above the level of the ventriculo-aortic junction (VAJ) at the nadir of the non-coronary cusp. Importantly, the aortic annulus itself is preserved and not incised. This maneuver opens the aortic root and usually allows for implantation of a prosthetic valve one size larger than the annulus would typically accommodate.

Patch selection and tailoring

We used a bovinum pericardium patch for our enlargement, although other materials may be used such as Dacron or autologous pericardium. The patch area is typically sized approximately 5 cm × 5 cm × 7 cm in a triangular shape. A triangular geometry was selected for the patch as it closely matches the shape of the defect in the non-coronary sinus with the base of the triangle oriented towards the aortic annulus and the tip oriented towards the distal ascending aorta. The size of the patch was chosen to provide an enlargement large enough to fit the prosthesis without providing redundant aorta that could lead to aneurysmal geometry after closure. It is preferable to create a larger patch and trim the excess rather than to be left with an insufficient patch, as it may be tailored during sewing.

Patch implantation and hemostatic reinforcement

A 4-0 polypropylene running suture was used to sew the patch beginning at the base of the enlargement incision, with several open bites taken initially before parachuting the patch down into position. A second reinforcing suture layer (often 5-0 polypropylene) was run over the primary line, again starting at the base and running up each side of the patch. The redundancy of a second suture layer is specifically intended to mitigate bleeding from the patch line below the sewing ring, a complication which can be potentially catastrophic and worth the additional minutes to prevent it with a second running suture.

Re-sizing and prosthesis “test positioning”

Before placing valve sutures, we placed the prosthesis sizer into the aortic root to observe how the prosthetic valve would be oriented and to test the size. The sewing ring of the valve sits on the annulus under the coronary ostia, while the valve can be tilted above the annulus in the non-coronary sinus, helping to determine where sutures should traverse the patch and transition zone.

Annular sutures and transition-zone strategy

Standard 2-0 non-absorbable braided sutures with pledgets were placed around the annulus. Large pledgets were used to avoid tearing through the thin pericardium. We routinely use horizontal mattress sutures with pledgets on the ventricular size for this technique. In the transition zone between the native aortic wall and the patch, sutures were placed with an outside-in fashion such that the pledgets lay on the outside of the aorta and patch. Furthermore, a curvilinear trajectory was used to support supra-annular seating of the valve in the patch region. A second layer of pericardium can be added in this area to avoid tearing through the initial patch.

Seating the prosthesis and securing the patch interface

The sutures were passed through the prosthetic valve sewing ring, the valve was seated, and knots were tied. Leaflet mobility was then confirmed, and a systematic check for paravalvular gaps that could possibly lead to paravalvular leaks was performed.

Aortotomy closure and final patch trimming

The aortotomy was closed with a running polypropylene suture. The patch was then trimmed appropriately and secured toward the top of the aortotomy to reconstruct the final contour of the ascending aorta. The CBP and aortic cross-clamp times were 106 min and 91 min, respectively.

Postoperative considerations and tasks

Standard postoperative care following AVR was applied. No additional postoperative anesthetic considerations were required. Particular attention was paid to early transthoracic echocardiographic assessment of prosthetic valve function and detection of paravalvular leak or conduction disturbances. Possible postoperative complications of this technique are largely similar to that of standard techniques. Postoperative follow-up was conducted in accordance with the standards for post-AVR care. The patient in the presented clinical case was discharged home on post-operative day five. At the six-month follow-up, the patient was asymptomatic with a transthoracic echocardiogram demonstrating no aortic regurgitation along with peak and mean transvalvular gradients of 12 and 24 mmHg, respectively.

Tips and pearls

Successful application of ARE begins with meticulous preoperative planning and a deliberate, rather than reactive, surgical strategy. The need for enlargement should be anticipated based on patient BSA, annular measurements, and the hemodynamic profile of the intended prosthesis, allowing the procedure to be performed in a controlled manner. During the operation, careful annular decalcification is essential to avoid underestimating true annular dimensions and to ensure accurate sizing. When enlargement is required, the incision should be executed with precision and respect for anatomic landmarks, particularly to preserve the aorto-mitral curtain, thereby minimizing disruption of the mitral apparatus and simplifying reconstruction relative to other established techniques. Patch selection and tailoring are critical steps; the patch should be intentionally oversized and subsequently trimmed to avoid tension, and meticulous attention must be paid to hemostasis at the patch–annulus interface. Reinforcement of the patch suture line beneath the prosthetic sewing ring, as emphasized in the technical descriptions, is strongly recommended to reduce the risk of bleeding, which can be difficult to control once the valve is seated. During valve implantation, suture placement across the transition zone between native tissue and patch should favor larger bites and pledgets to prevent patch tearing and to support stable supra-annular seating of the prosthesis. Finally, thorough intraoperative assessment of prosthetic valve seating, leaflet mobility, and paravalvular integrity is essential before aortotomy closure, as careful execution of these steps directly translates into durable hemodynamic performance and excellent clinical outcomes.

Discussion

ARE represents one of the most effective surgical strategies to prevent PPM during AVR, particularly in patients with a small annulus and large BSA (9). Despite its long-standing description and technical maturity, ARE remains inconsistently adopted in routine surgical practice. This hesitancy persists even as evidence has accumulated demonstrating that PPM is not a benign phenomenon and that surgical enlargement can be performed safely without incremental operative risk (9,16-18). The technique described in the present manuscript builds upon well-established principles of ARE while introducing a deliberate modification of the Nicks procedure aimed at lowering technical complexity and broadening applicability where technical complexity may be a limiting or prohibitive factor.

From a technical perspective, this technique offers a clear and reproducible method for ARE. The stepwise approach highlights careful annular exposure, controlled extension of the aortotomy, appropriate patch sizing, and—importantly—reinforcement of the patch suture line beneath the prosthetic sewing ring to minimize the risk of bleeding. To reduce the likelihood of paravalvular leaks, a small nerve hook may be used to systematically assess the prosthesis for loose sutures or potential gaps; any identified defects should be corrected with additional sutures. Following aortic closure and restoration of cardiac activity, intraoperative assessment with transesophageal echocardiography is essential to confirm adequate valve function and assess for possible paravalvular leaks. Particular attention should be directed to the region of the patch to ensure that its geometry does not contribute to leaks. Extra care should be taken to not continue the aortotomy through the annulus to avoid injuring the conduction system as it crosses through the atrioventricular component of the membranous septum. A successful ARE, as described in this technique, is defined by implantation of a prosthesis larger than the native annulus, thereby avoiding PPM, achieving transvalvular gradients within manufacturer-recommended limits, and ensuring the absence of paravalvular regurgitation. These principles remain central to any successful enlargement strategy and are preserved in the present technique. However, classical approaches described by others typically involve incision across the annulus and into the anterior mitral leaflet or aorto-mitral curtain. While this maneuver reliably achieves enlargement and allows implantation of a larger prosthesis, it also introduces additional reconstructive steps and potential risks related to mitral valve integrity, VAJ stability, and bleeding from the surgical site (19,20). Conceptually, this technique represents an evolution rather than a departure from classical ARE: the goal remains implantation of an adequately sized prosthesis, but with reduced surgical complexity.

The importance of adopting a proactive, planned approach to ARE is strongly supported by contemporary outcome data. In the largest analysis to date, Rocha and colleagues demonstrated that surgical ARE, when added to AVR, was not associated with increased in-hospital mortality or postoperative adverse events, even after multivariable adjustment and propensity matching (9). Notably, this finding held true despite longer cross-clamp and CPB times, reinforcing that the physiological cost of enlargement is outweighed by its long-term hemodynamic benefits. These data challenge the lingering perception that ARE is inherently high-risk and instead support its routine consideration in appropriately selected patients.

Beyond immediate surgical outcomes, the relevance of ARE has expanded in the era of transcatheter valve-in-valve therapy. As bioprosthetic valve use continues to increase, particularly in younger patients, the likelihood of future reintervention is substantial. Small surgical prostheses are a risk factor for suboptimal valve-in-valve hemodynamics and persistent gradients (21). Rocha et al. highlight that surgical strategies aimed at enlarging the annulus at the index operation may facilitate future transcatheter therapies by allowing implantation of larger surgical valves with more favorable internal diameters (9). In this context, the present technique aligns with a forward-looking surgical philosophy that prioritizes lifetime valve management rather than isolated procedural success. Although ARE is an invaluable tool in the cardiac surgeon’s toolbox, it is not the only technique currently available for AVR in the cases of a small aortic annulus. Sutureless aortic valve prostheses have been developed to decrease CPB times without compromising clinical outcomes (22). Some studies have investigated the use of sutureless aortic valves in patients with a small aortic annulus and have demonstrated comparable hemodynamic outcomes, although there have not been any randomized trials or established long-term outcomes (23,24). Other techniques include stentless aortic valve prostheses, use of aortic homografts, or the Ozaki procedure whereby a new aortic valve is constructed using the patient’s own pericardium. Also, the Ross procedure is an excellent choice for young patients with severe aortic stenosis (25).

Several limitations warrant acknowledgment. This manuscript describes a surgical technique and is not intended to provide comparative outcome data relative to other enlargement strategies. Long-term durability and reproducibility across different surgical environments remain to be established. Moreover, while preservation of the aorto-mitral curtain is conceptually attractive, it does not obviate the need for advanced surgical judgment, careful patient selection, and familiarity with root anatomy. The technique should therefore be viewed as a complementary addition to, rather than a replacement for, existing enlargement methods. A limitation of our modified technique is the degree to which the aortic root can be enlarged without altering the structure of the aortic annulus. While a prosthetic valve that is one size larger than the annulus can be incorporated without hemodynamic compromise, a valve that is two or more sizes larger may result in the formation of a sub-valvular pannus which may risk prosthetic malfunction over time.

Contraindications to the ARE technique outlined in this publication are similar to those of other established ARE techniques. In scenarios of extreme calcification and a fragile aortic annulus, root reconstruction can be dangerous and risk annulus disruption. Furthermore, in patients with abnormally low coronary ostia, the placement of a prosthetic valve above the native surgical aortic annulus may not be possible.

Conclusions

Management of the small aortic annulus remains a central challenge in contemporary aortic valve surgery, particularly in an era defined by increasing bioprosthetic valve use, longer patient life expectancy, and the growing relevance of future valve-in-valve transcatheter interventions. Surgical ARE should therefore be regarded not as an exceptional maneuver, but as an integral component of a comprehensive valve replacement strategy aimed at optimizing long-term outcomes. The modified ARE technique described in this manuscript builds upon decades of accumulated surgical experience and robust outcome data demonstrating the safety of annulus and root enlargement. By preserving the aorto-mitral curtain while enabling implantation of an adequately sized prosthesis, this approach seeks to reduce anatomical disruption and technical complexity without compromising the fundamental objectives of enlargement. When applied in a planned and methodical fashion, the technique allows surgeons to address annular constraints proactively, rather than accepting suboptimal prosthesis sizing or resorting to intraoperative compromise. Preservation-focused ARE represents a rational evolution of established surgical principles. Adoption of such techniques, guided by careful preoperative planning and individualized patient assessment, may expand surgeon comfort with enlargement strategies and promote more consistent avoidance of PPM. As surgical and transcatheter therapies continue to converge, proactive annular management will remain a defining element of durable and patient-centered AVR.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0006/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0006/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-2026-1-0006/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this surgical technique and accompanying video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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