Inverted Y Annular Enlargement in Bicuspid Aortic Valve: A Stepwise Surgical Approach

A 45-year-old female with a body surface area (BSA) of 1.68 m² (weight: 64 kg, height: 154 cm) presented with a one-year history of progressively worsening dyspnea, classified as New York Heart Association (NYHA) Class III. She also reported symptoms of chest heaviness and presyncope. 

At the time of admission, the patient was hemodynamically stable, and jugular venous pressure (JVP) was within normal limits. Cardiovascular examination revealed the apex beat at the left fifth intercostal space with a heaving impulse. The first heart sound (S1) was normal, while the second heart sound (S2) was soft and delayed. A grade 4/6 ejection systolic murmur was audible. 

Transthoracic echocardiography (TTE) demonstrated a bicuspid aortic valve (BAV) with Sievers Type I morphology, showing fusion of the right coronary cusp (RCC) and non-coronary cusp (NCC). The valve leaflets were calcified with restricted mobility. Peak and mean transvalvular gradients were 92 mmHg and 52 mmHg, respectively. The aortic valve area (AVA) measured 0.6 cm², and the annular diameter was 1.72 cm. Left ventricular (LV) systolic function was preserved. 

Following systemic heparinization, aortobicaval cannulation was performed. An autologous pericardial patch was harvested and treated with 0.6 percent glutaraldehyde for 10 minutes, followed by saline rinsing for another 10 minutes in preparation for aortic root enlargement (ARE). 

After aortic cross-clamping and cardioplegic arrest, a right superior pulmonary vein (RSPV) vent was placed. The aortotomy was initiated approximately 2 cm above the sinotubular junction (STJ) and extended obliquely toward the left coronary cusp (LCC)–non-coronary cusp (NCC) commissure down to the annulus. Aortic stay sutures were then positioned. Intraoperatively, the BAV anatomy revealed fused RCC and NCC. Following leaflet excision, the aortotomy was extended further, and the annulus was incised between the LCC and NCC. This incision was directed into the LCC and NCC sinuses to facilitate annular enlargement. 

In BAV cases, due to the presence of a fibrous raphe, variable sinus geometry, and often aberrant coronary ostial positions, precise planning of the inverted Y incision and strategic suture placement are essential. A rectangular autologous pericardial patch was sutured to the incised annular margins using 3-0 polypropylene continuous sutures. 

The thickened, calcified valve leaflets were excised. The fibrous raphe was meticulously debrided, and calcific deposits were removed with care to preserve annular continuity and avoid injury to underlying myocardial tissue. 

The aortotomy was then extended in an inverted Y fashion laterally into the fibrous tissue toward the left fibrous trigone and inferiorly toward the nadir of the NCC. The raphe between the RCC and NCC was avoided to maintain structural integrity. This delineated the suture line for patch placement. Adequate annular enlargement was confirmed through direct measurement. 

The pericardial patch was trimmed to the appropriate dimensions. Stay sutures were placed at its four corners to aid manipulation. A 4-0 polypropylene suture on a 16 mm SH needle was used for patch fixation. Suturing commenced centrally and proceeded toward the NCC. After several initial stitches, the patch was parachuted down, and sewing continued toward the NCC sinus. Bites were placed equidistantly in a forehand manner up to the STJ. The opposite arm of the suture was similarly run from the center toward the LCC extension. Any remaining calcific deposits were excised. 

The neoaortic annulus was delineated on the patch, and a 25 mm TTK Chitra single-leaflet mechanical prosthetic valve was selected. Non-pledgeted 2-0 polyester annular sutures on 17.6 mm needles were placed in a noneverting fashion from the LCC–RCC commissure toward the LCC, and then from the RCC–LCC commissure toward the RCC. Given the asymmetry due to the fused RCC and NCC, suture positions were modified to form a circular, evenly distributed sewing ring. Sutures traversed the pericardial patch from the exterior to the interior along the marked annular contour. These sutures were then passed through the sewing ring of the valve in a uniformly spaced fashion. The prosthesis was parachuted into place and secured by tying all sutures. 

Closure of the aortotomy was achieved using the pericardial patch, thereby promoting uniform dilation of the aortic root and proximal ascending aorta while maintaining anatomical contour. The final configuration yielded a smoothly contoured neoaorta without distortion. 

While the annular enlargement achieved via the inverted Y technique (Bo Yang modification) in BAV is generally less than that attainable in tricuspid aortic valves (TAV), it remains particularly well-suited to BAV anatomy when compared with conventional ARE techniques. 

Postoperative TTE revealed a marked reduction in transvalvular gradient, with a mean gradient of 7 mmHg. There was no evidence of transvalvular or paravalvular regurgitation. 

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