Patch Enlargement of the Aortic Annulus using the Manouguian Technique

The aortotomy from which the Manouguian root enlargement is most readily applied is a relatively low, transverse one. A hockey-stick-type aortotomy which initially descends into the middle of the noncoronary sinus will be more complex to close if diverted posteriorly to the commissure between right and left cusps.

The Manouguian technique, in contrast to the Nicks, places the incision into the anterior leaflet of the mitral valve squarely in the center of the anterior leaflet. Recall that the right fibrous trigone of the mitral valve lies roughly at the base of the noncoronary cusp and the left fibrous trigone lies roughly at the base of the left coronary cusp beneath the left main. Therefore, incisions made deep into the noncoronary cusp, as is the case for the Nicks annular enlargement, run the risk of damage to the coapting surface of the mitral valve if not diverted medially. With the Manouguian, no such correction away from the free edge of the leaflet is necessary.

A patch is then sewn into the defect in the anterior leaflet. The patch material may be autologous pericardium, glutaraldehyde-fixed bovine pericardium, or Dacron patch material. I prefer to use a running suture line beginning at the apex of the incision and carrying it just far enough above the surgical annulus of the aortic valve to permit placement of valve sutures. This leaves the aortotomy open as widely as possible for placement of the valve.

The valve sutures are then placed. It is my preference to use horizontal mattress sutures with pledgets on the ventricular side. I anticipate that the patch will enlarge the root by one valve size and select my valve accordingly. In other words, if only a 19-mm valve fits before root enlargement, I select a 21-mm valve to insert after patch augmentation of the annulus.

I place the valve sutures through the pericardial patch from outside to inside, using one mattress suture at each end of the patch, overlapping my continuous suture line, thereby reinforcing the patch closure.

At this point the valve can be readily seated and the aortotomy closed with the continuous suture line. The large patch may be used to close the entire aortotomy, or more commonly I will make the patch just large enough to correct the defect in the root, ending it at my transverse suture line above the sinotubular junction.