Minimizing transaortic valve gradient in a young female with a large body habitus and small annulus: a case report.

BACKGROUND: Aortic valve replacement in the setting of a small aortic anulus and a large body habitus is challenging. A surgical aortic valve replacement (AVR) implanted circumferentially onto this native annulus will predictably result in patient-prosthesis mismatch (PPM). We discuss the decision making process for the management of this patient. CASE PRESENTATION: We report our management strategy for a younger patient (55 years old) with a very large body habitus (body mass index = 63.3 kg/m2). She had severe aortic stenosis in a small aortic annulus (diameter = 18 mm) and moderate-severe mitral stenosis. She underwent double mechanical valve replacement which included a Y-incision root enlargement to reduce obstruction to the left ventricular outflow tract (LVOT) by displacing the structural components of the On-X valve into the enlarged root away from the LVOT. CONCLUSIONS: A Y-incision root enlargement is an effective strategy to maximize use of the native LVOT to avoid PPM. In the setting of a mechanical AVR, this is expected to result in favorable long-term outcomes.