Manouguian Procedure

The Manouguian technique is a posterior aortic root enlargement technique used when the patient has a small aortic annulus and is undergoing aortic valve replacement. There are multiple aortic root enlargement techniques used to enlarge a small aortic root and outflow tract so that a larger aortic valve may be placed. The placement of a larger aortic valve allows the patient to avoid patient prosthesis mismatch (PPM) and structural valve deterioration. Implantation of a prosthetic valve of adequate size relative to the patient body surface area (BSA) can decrease the overall morbidity and mortality for the patient. The well-known postoperative complications associated with patient prosthetic mismatch have gained the attention of cardiac surgeons, so these techniques are used when a small aortic annulus with small outflow tracts is diagnosed. The Manouguian technique involves making an incision and extending it posteriorly through the commissure between the left coronary cusp and noncoronary cusp. The incision can then be carried onto the anterior mitral valve leaflet. There are multiple aortic root enlargement techniques, with the Nicks-Nunez procedure being another posterior aortic enlargement technique. The Nicks-Nunez technique involves making a vertical incision through the commissure. The incision is then carried between the left coronary cusp and noncoronary cusp all the way to the inner leaflet triangle, thus giving a larger aortic outflow tract. The Nicks-Nunez technique usually allows the placement of at least one valve size bigger. The Konno-Rastan procedure is an anterior aortic outflow tract enlargement technique. The Konno-Rastan technique involves making an incision 2 to 3 mm to the right of the anterior aortic valve commissure with an incision of the infundibular septum. When making this incision, care must be taken to not damage the conduction system or the first septal branch of the left anterior descending coronary artery. The aortic outflow tract can then be sized for a larger aortic valve. The overall goal is to recognize small aortic roots so that the best decision can be made to treat the small aortic root with an enlargement technique to avoid the associated morbidities of patient prosthesis mismatch.