@article{ASJ120527,
author = {Sam Papernick and Navneet Kang and Hugo Monteiro Neder Issa},
title = {A modified surgical aortic root enlargement technique preserving the aorto-mitral curtain to prevent prosthesis-patient mismatch during aortic valve replacement},
journal = {AME Surgical Journal},
volume = {6},
number = {0},
year = {2026},
keywords = {},
abstract = {Aortic valve replacement (AVR) in patients with a small aortic annulus remains a technical challenge, particularly in the context of an increasing use of bioprosthetic valves and the anticipated need for future valve-in-valve transcatheter interventions. One of the key considerations that influences surgical valve replacement is prosthesis-patient mismatch (PPM). PPM is associated with impaired hemodynamics, reduced left ventricular mass regression, and compromised long-term outcomes. Surgical aortic root or annular enlargement (ARE) is an established strategy to mitigate PPM and enable implantation of adequately sized prostheses. Although multiple techniques have been described, most conventional approaches involve disruption of the native aorto-mitral curtain, increasing technical complexity. We describe a modified ARE technique that enables implantation of a larger aortic prosthesis while preserving the integrity of the aorto-mitral curtain. The technique is illustrated through a representative clinical case of a 60-year-old woman with symptomatic severe aortic stenosis, a small aortic annulus, and elevated risk for PPM based on body surface area and prosthesis hemodynamic profile. Preoperative planning identified the need for a minimum size of 23 mm bioprosthetic valve to avoid PPM, necessitating the need for ARE. The procedure was successfully performed, followed by an uncomplicated postoperative course and excellent mid-term clinical and echocardiographic outcomes. This manuscript provides a step-by-step description of the technique, discusses key technical considerations, and situates the approach within the context of established enlargement strategies. By avoiding an incision into the aorto-mitral curtain, this modification aims to simplify the procedure relative to widely established techniques while maintaining the proven benefits of ARE. This technique represents a safe addition to the surgical armamentarium for AVR in patients with a small aortic annulus.},
issn = {2788-578X}, url = {https://asj.amegroups.org/article/view/120527}
}