Expanding indications, narrowing margins: the renewed importance of aortic annular enlargement in the valve-in-valve era

We congratulate Yin et al. on their report describing surgical explantation of a transcatheter aortic valve bioprosthesis followed by Y-incision aortic annular enlargement in a patient with a small aortic annulus (1). This report highlights a clinically important and increasingly encountered scenario in the contemporary era of aortic valve treatment.

The rapid expansion of transcatheter aortic valve implantation (TAVI) has profoundly altered the treatment landscape of aortic valve disease. Initially reserved for high-risk or inoperable patients, TAVI is now increasingly applied to younger and lower-risk populations, supported by accumulating evidence demonstrating its short- and mid-term safety and efficacy (2,3). At the same time, contemporary surgical approaches, including minimally invasive aortic valve replacement, have continued to evolve and have demonstrated favorable early and midterm outcomes, underscoring the ongoing role of surgical treatment in the era of expanding transcatheter therapies (4). In parallel, valve-in-valve (ViV) TAVI has emerged as an established strategy for failed bioprosthesis valves, contributing to a growing trend toward the use of TAVI even in younger patients at the time of initial treatment (5). These developments have led to a paradigm shift toward the concept of “lifetime management”, in which the initial intervention is considered within the context of future reinterventions, including ViV-TAVI procedures.

Within this framework, the anatomical and hemodynamic consequences of the initial procedure become critically important. In particular, implantation of an adequately sized prosthetic valve is essential to avoid patient-prosthesis mismatch (PPM) and to preserve the feasibility of future ViV-TAVI. However, this objective is often difficult to achieve in patients with a small aortic annulus, where both surgical and transcatheter options are inherently constrained.

The present report provides a critical example of this challenge. In the case described, prior TAVI in a small annulus resulted in prosthetic valve dysfunction with significant gradients and regurgitation, and ViV-TAVI was deemed unsuitable due to the high risk of PPM. This clinical course underscores an important limitation of transcatheter therapy in this anatomical subset and highlights the need for careful initial strategy selection.

To better understand the implications of this report, it is important to recognize the role of aortic annular enlargement. Classical aortic annular or root enlargement techniques such as the Nicks, Manouguian, and Konno procedures have long been used to address small annuli, each offering different balances between technical complexity and degree of enlargement.

In the present case, the application of the Y-incision technique enabled implantation of larger prosthetic valves without violating the mitral valve or left atrium (1). This approach has gained widespread attention due to its relative simplicity and effectiveness (6). However, it is not without drawbacks. Because the enlargement is primarily supra-annular and does not directly enlarge the left ventricular outflow tract (LVOT), a mismatch between the enlarged prosthetic valve and the native LVOT may persist, potentially resulting in residual gradients. In addition, inward tilting of the implanted valve has been described as a potential anatomical concern, which may reduce the effective valve-to-coronary relationship and complicate future ViV-TAVI planning. Therefore, when selecting an enlargement technique, it is important to consider not only the achievable prosthetic valve size but also the anatomical level of enlargement required, including the aortic annulus, root, and LVOT (7-10).

In response to these challenges, hybrid or combined approaches have recently been proposed. By integrating the advantages of multiple techniques—for example, combining Nicks with Y-incision or Konno-type extension—surgeons may achieve more balanced enlargement of both the annulus and LVOT while mitigating the limitations of each individual method. Indeed, combined anterior and posterior enlargement strategies have been shown to facilitate implantation of substantially larger prostheses in complex cases (11).

The authors highlight an important and increasingly encountered clinical scenario in the era of lifetime management (12). The current evidence underscores that aortic annular or root enlargement is no longer merely an adjunctive technique for selected patients, but rather a central component of surgical planning. As indications for transcatheter therapies continue to expand, the importance of optimizing the initial surgical procedure will only increase.

In conclusion, the case presented by Yin et al. (1) provides valuable insight into the management of aortic valve disease and underscores the need for a forward-looking perspective. A comprehensive understanding of annular anatomy, prosthesis selection, and aortic annular or root enlargement techniques is essential for optimizing both immediate and long-term outcomes. The integration of surgical and transcatheter strategies represents the next frontier in valve therapy, and continued innovation in annular enlargement will play a pivotal role in shaping this evolving paradigm.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0029/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0029/coif). The authors have no conflicts of interest to declare.

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References

1. Yin K, Titsworth M, Yokoyama Y, et al. Y-incision aortic annular enlargement after surgical explantation of transcatheter aortic valve bioprosthesis. Ann Cardiothorac Surg 2025;14:173-5. [Crossref] [PubMed]
2. Meeus R, Dhondt P, Hariyanto J, et al. Transcatheter aortic valve replacement in low-risk patients: an updated meta-analysis of randomized controlled trials. Int J Cardiol Heart Vasc 2025;59:101692. [Crossref] [PubMed]
3. Shuhaiber J. Transcatheter Aortic Valve Replacement for Patients at Low Risk and Younger Patients-A Contemporary View. JAMA Intern Med 2026;186:400-1. [Crossref] [PubMed]
4. Furutachi A, Nakamura Y, Niitsuma K, et al. Midterm Outcomes of Minimally Invasive Aortic Valve Replacement via Right Lateral Minithoracotomy. Innovations (Phila) 2025;20:48-56. [Crossref] [PubMed]
5. Webb JG, Mack MJ, White JM, et al. Transcatheter Aortic Valve Implantation Within Degenerated Aortic Surgical Bioprostheses: PARTNER 2 Valve-in-Valve Registry. J Am Coll Cardiol 2017;69:2253-62. [Crossref] [PubMed]
6. Yang B. A novel simple technique to enlarge the aortic annulus by two valve sizes. JTCVS Tech 2021;5:13-6. [Crossref] [PubMed]
7. Chen SA, Do-Nguyen CC, Titsworth M, et al. Aortic Annular Enlargement: Y-Incision Rationale, Technique, and Outcomes. Ann Thorac Surg 2025;119:1151-65. [Crossref] [PubMed]
8. Nakamae K, Niinami H, Domoto S, et al. A New Technique for Aortic Annular and Outflow Enlargement: Combined Y-Incision and Nicks Procedures. Ann Thorac Surg Short Rep 2024;2:799-803. [Crossref] [PubMed]
9. Yang B. Aortic annular enlargement with Y-incision/rectangular patch. Ann Cardiothorac Surg 2024;13:294-302. [Crossref] [PubMed]
10. Dvir D, Leipsic J, Blanke P, et al. Coronary obstruction in transcatheter aortic valve-in-valve implantation: preprocedural evaluation, device selection, protection, and treatment. Circ Cardiovasc Interv 2015;8:e002079. [Crossref] [PubMed]
11. Ribeiro HB, Rodés-Cabau J, Blanke P, et al. Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry. Eur Heart J 2018;39:687-95. [Crossref] [PubMed]
12. Matsuda M, Yajima S, Yoshioka D, et al. The Combined Konno-Nicks Procedure for Severely Stenotic Aortic Root and Left Ventricular Outflow Tract. JACC Case Rep 2026;31:106544. [Crossref] [PubMed]