Aortic Root Enlargement in Patients With Small Aortic Annulus Undergoing Double Valve Replacement: A Retrospective Comparative Cohort Study


  • Yasser Shaban Mubarak, MD Department of Cardiothoracic Surgery, Minia University, Minia, Egypt
  • Ahmed Abdel Rahman Abdel Jawad, MD Department of Cardiothoracic Surgery, Cairo University, Cairo, Egypt



Aortic Root Enlargement, Small Aortic Annulus, Double Valve Replacement, Patient-Prosthesis Mismatch, Nick`s / Manouguian procedure


Background: Small aortic annulus (AA) is a big issue during aortic valve replacement (AVR), necessitating replacement of an undersized prosthetic valve especially with double valve replacement (DVR). Despite the fact that small aortic valve prostheses can lead to prosthesis-patient mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures, fearing morbidity and mortality.

Objective: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus (<18 mm) undergoing double valve replacement.

Methods: The study included 100 consecutive patients who underwent DVR for combined rheumatic aortic and mitral valve diseases, between January 2016 and September 2020. Only 50 patients had ARE with DVR. ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick's or Manouguian procedures. The estimated postoperative endpoints were mortality, effective orifice areas (EOA), mean aortic pressure gradient (PG), and valve-related complications. The shortest postoperative follow-up period was 6 months.

Results: The study included 30 male and 70 female patients with mean age of 35±20 years, body surface area (BSA) of 1.7 ± 0.3 m2, aortic annulus diameter was 1.4 ± 0.4 mm, aortic orifice area was 0.8 ± 0.1 cm2, and mean pressure gradient 85 ± 2.5 mmHg. During the follow-up period, there was a mild to moderate paravalvular leak (1%) with 1% heart block and residual gradient on prosthetic aortic valve; this was all in DVR alone.

Conclusion: Enlargement of the aortic root by Nick's or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.


Ahsan M, Rahman L, Shariful A, Arifur M. 2020. Case Report: Aortic Root Enlargement In Case of Double Valve Replacement. KYAMC Journal. 11(2): 108-10.

Ankit M, Ravi G, Debmalya S, et al. 2020. Konno Procedure for Managing Small Aortic Root during Aortic Valve Replacement Surgery: An Experience of 12 Cases. W J Cardiovasc Surg. 10: 24-31.

Fallon JM, DeSimone JP, Brennan JM, O’Brien S, Thibault DP, DiScipio AW, et al. 2018. The incidence and consequence of prosthesis patient mismatch after surgical aortic valve replacement. Ann Thorac Surg. 106:14–23.

Feindel CM. 2006. Aortic Root Enlargement in the Adult. 03.002. doi:10.1053/j.optechstcvs.2006.03.002

Fuster RG, Argudo JA, Albarova OG, et al. 2005. Patient-prosthesis mismatch in aortic valve replacement: really tolerable? Euro J Cardiothorac Surg. 27: 441–49.

Grubb KJ. 2016. Aortic Root Enlargement during Aortic Valve Replacement: Nicks and Manouguian Techniques. Operative Techniques in Thorac Cardiovasc Surg. 20: 206-18.

Muppiri VK, Ali SN, Venkat KR, Rama KL. 2011. Aortic root enlargement in patients undergoing double valve replacement for rheumatic etiology–preliminary results. Indian J Thorac Cardiovasc Surg. 27(4):161–64.

Rocha R, Manlhiot C, Feindel C, Yau T, Mueller B, et al. 2018. Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement. Circulation. 137:1585–94.

Sa´ MPBO, Carvalho MMB, Sobral Filho DC, Cavalcanti LRP, Diniz RGS, et al. 2019. Impact of surgical aortic root enlargement on the outcomes of aortic valve replacement: a meta-analysis of 13174 patients. Interact CardioVasc Thorac Surg. doi:10.1093/icvts/ivy364.

Sundt TM. 2006. Patch Enlargement of the Aortic Annulus using the Manouguian Technique. 03.003.

Timala RB. 2010. How I do it" Aortic Valve Replacement in case of Double Valve Replacement. NHJ. 7(1):50-53.

Wang B, Yang H, Wu S, Cao G, Yang H. 2013. Obesity and the risk of late mortality after aortic valve replacement with small prosthesis. J Cardiothorac Surg. 8: 174 - 75.



How to Cite

Mubarak, Y., & Abdel jawad, A. A. R. (2021). Aortic Root Enlargement in Patients With Small Aortic Annulus Undergoing Double Valve Replacement: A Retrospective Comparative Cohort Study. The Heart Surgery Forum, 24(2), E239-E242.