Revisiting the Manougian Technique With Double-Patch

In the treatment of aortic valve disease, there is increasing recognition of the adverse impact of patient–prosthesis mismatch, which has been associated with early valve failure and poorer long-term outcomes. This awareness has renewed surgical interest in aortic root enlargement techniques that enable the implantation of larger prostheses. However, the more commonly employed enlargement methods do not extend into the left ventricular outflow tract and, therefore, carry the risk of valve tilt, which can impair hemodynamic performance, compromise durability, and limit the feasibility of future valve-in-valve transcatheter aortic valve replacement.  

The Manougian technique is a posterior root enlargement procedure that extends into the anterior mitral leaflet, allowing the prosthesis to sit in the true annular plane. Despite this advantage, the technique has not been widely adopted, largely due to concerns about disrupting mitral valve function and inducing new regurgitation. 
 
The authors present a double-patch modification of the Manougian technique as a simple and reproducible alternative. In this approach, the aortotomy was extended through the left non-commissure and then carried under the annulus leftward toward the left fibrous trigone and rightward toward the right fibrous trigone, similar to a Y-incision. The midpoint of the anterior mitral leaflet was then incised at the level of the aorto-mitral curtain to enter the left atrium. An autologous pericardial patch was used to reconstruct the diamond-shaped defect, closing both the anterior mitral leaflet and the left atrial dome. A second Dacron patch was used to close the posterior defect in the aorta. This technique achieves extensive annular enlargement and allows for the implantation of larger prostheses in the true annular plane. 

References

1. Sá MP, Jacquemyn X, Van den Eynde J, Tasoudis P, Dokollari A, Torregrossa G, Sicouri S, Clavel MA, Pibarot P, Ramlawi B. Impact of Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement: Meta-Analysis of Kaplan-Meier-Derived Individual Patient Data. JACC Cardiovasc Imaging. 2023 Mar;16(3):298-310. doi: 10.1016/j.jcmg.2022.07.013. Epub 2022 Sep 16. PMID: 36648055.
2. Hassler KR, Monaghan K, Green C, Yang B. How-I-Do-It: Aortic Annular Enlargement - Are the Nicks and Manouguian Obsolete? Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2024;27:25-36. doi: 10.1053/j.pcsu.2023.12.005. Epub 2023 Dec 23. PMID: 38522868.

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