Minimal Invasive Aortic Valve Replacement with Aortic Annular Enlargement

All articles of this category (opens in new window) Background: Many factors have contributed to grow the complexity of the surgical aortic valve replacement (SAVR) after the establishment of the transcatheter technique (TAVI), such as decreased routine, bicuspid, and severe calcified valves are presented very often, young patients with request for minimal invasive surgery. There is clear clinical evidence of beneficial outcomes if larger valves are implanted during SAVR. Under these conditions, aortic annular enlargement (AAE) during SAVR in a minimal invasive setting appears relevant. Methods: Between 2018 and 2025, 22 consecutive patients with symptomatic aortic stenosis underwent SAVR with AAE (Nicks or Manougian procedure) in a minimally invasive fashion through minimal J-sternotomy or through right lateral minithoracotomy. The primary endpoint was a device success as defined by the VARC-3 criteria. Second end-points were: early safety at 30 days and clinical efficacy at 1 year as defined by VARC-3 criteria. The mean follow-up time was 3.2 ± 2 years. Results: The mean age was 60.2 ± 8.7 years. The mean EuroScore II was 1.1 ± 0.4%. There were used bovine pericardial patches and autologous pericardial patches in 16 (72.7%) and 6 (27.3%) patients, respectively. The device's success was 100%. No patients died at 30 days, no redo or re-intervention, and no access-related cardiac complications were registered. The mean gradient was 10.2 ± 3.2 mmHg. The early safety was 91%. One re-thoracotomy for bleeding (4.5%), and one patient experienced a stroke (4.5%). There was no kidney injury, no new pacemaker, and no aortic regurgitation. Clinical efficacy at 1-year was 100%, without mortality, stroke, or hospitalization for procedure- or valve-related causes. Three events occurred during 63.6 patient-years (RMST 6.18 years, τ = 7.39 years). The incidence rate was 0.047/PY (4.72 per 100 PY; 95% CI: 0.0097–0.138/PY, 0.97–13.78 per 100 PY). Conclusion: SAVR with AAE in a minimal invasive setting shows very good early and mid-term results and fulfills all requirements of contemporary visions of treatment of aortic stenosis and promises a solid surgical concept in the post-TAVI era in the future. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany