Yang Procedure and Double Valve Replacement Technique

Prof. Bo Yang first described a Y-incision rectangular patch aortic annular enlargement technique, and it is one of the posterior aortic annular enlargement techniques that is simpler than giving 3 to 4 valve size enlargements. This group renamed it after Prof. Yang, with his consent, as the Yang procedure.

The Patient

The patient is a forty-five-year-old woman diagnosed with rheumatic mixed aortic and mitral valve disease, a small annulus, and complicated by infective endocarditis with a previous embolic CVA. The procedure was completed via median sternotomy with aortobicaval cannulation and retrograde cardioplegia for myocardial preservation.

The Procedure

A low-lying oblique aortotomy was completed for valve exposure, which discovered a trileaflet stenotic fibrotic valve with vegetations and fused commissures classical of rheumatic heart disease. The valve was excised, the annulus admitted a 21 sizer, which was inadequate for the patient. A decision to proceed with the Yang procedure root enlargement was made. The oblique aortotomy was extended through the LCC-NCC commissure post.   

Surgeons then extended for the Y-limbs beneath, starting with the left limb beneath the LCC annulus until just before the muscular part, then the right limb beneath the NCC until the hard tissue of the right fibrous trigone, which was evident when cut into. The distance between ends of the limbs should be at least 3 cm long. It was evident that the aortic root had been adequately widened.

Attention was then diverted to the mitral valve, which was excised through a standard left atriotomy with partial posterior leaflet preservation. Interrupted pledgetted 2-0 polyester sutures were placed around the mitral annulus and put through the valve sewing ring of a 29 mm bioprosthetic valve. The valve was not seated but left covered with a wet gauze for later.

Next, attention was turned to the aortic area, where the bovine pericardial patch was slightly oversized. It was then sutured into place starting at the end of the left limb using a running 4-0 Prolene suture. The mitral valve sutures were evident underneath, and the aortomitral curtain position was maintained by not seating the mitral valve until the patch was sutured in place. The suture line was clearly visible and allowed for creating a secure anastomotic line with no areas out of vision. The suture line reached the end right limb, where the hard trigone tissue was evident. It was important to maintain tension to secure a competent anastomotic line.

The suture line was then carried up the right side of the divided commissure post until the top of the post, where it was tied to a new suture, maintaining a secure anastomosis. The other arm of the initial Prolene suture was then meticulously anchored to the corner at the end of the left Y limb for hemostasis, then carried up toward the left side of the divided post, where it was similarly tied to an additional suture at the top of the post. The suture line was inspected, noting the loosely lying mitral sutures not caught into the enlargement suture line. The root exposure allowed for adequate inspection of the suture lines. The enlarged annulus was sized, admitting a 27 mm sizer, and the new commissures were marked out along with the patch side new annulus.

Everted interrupted pledgetted 2-0 polyester sutures were placed starting on the right, then left native annulus, followed by the noncoronary native annulus. Then, transition sutures were placed on either side of the patch toward the marked new annulus. The remaining patch pledgetted sutures were placed from outside the patch at the level of the marked new annulus. The sutures were placed through the sewing ring of the prosthesis, which was similarly covered with a wet gauze. The mitral valve prosthesis was then seated, and the left atrium closed.

A size 27 mm Medtronic bioprosthetic aortic valve was tied in place, noting evidently that the valve did not obstruct the coronary ostia as a benefit of this enlargement. It was clear that the ostium was free, as the retrograde cardioplegia was seen flowing freely. The suture line beneath the seated large aortic valve prosthesis was inspected and the retraction of the aortomitral curtain by the seated mitral prosthesis noted, mitigating for the delay in seating the mitral prosthesis before securing the enlargement patch. 

The right arm of the Prolene was then continued, suturing the patch onto the aortotomy. The left end of the aortotomy was closed with a similar Prolene, then the left arm of the Prolene was continued upward. The patch was sutured and trimmed to size before completing the closure.

Conclusion

This case demonstrates why the Yang procedure is a favourable root enlargement technique—allowing for a large aortic prosthesis even in double valve replacement procedures. Double valve replacement is common in rheumatic heart disease predominant environments, and giving such patients a large prosthesis is important.   

References

1. Yang B. A novel simple technique to enlarge the aortic annulus by two valve sizes. J Thorac Cardiovasc Surg Tech. 2021; 5:13-16.
2. Nyamande D. Ramoroko PS. The Yang Procedure: Renaming the recently described “Y” incision/rectangular patch aortic annulus enlargement technique. J Thorac Cardiovasc Surg Tech. 2022.

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