Introduction
Rheumatic Heart Disease (RHD) is very common in developing countries. It
affects mainly mitral and aortic valve. It causes annular fibrosis, may
be lead to smaller AA. So, if smaller prosthesis is implanted, there is
a PPM, poor Left Ventricle (LV) mass regression, increases overload, and
low survival rate. With undersized prosthetic valve, patient can’t
maintain normal activity; produce symptoms of aortic stenosis (AS) and
PPM. Rahimtola first described the issue of PPM, if the
EOA of prosthetic valve is very small in relation to patient′s BSA[1-2] . Nicks and colleagues
first proposed posterior root enlargement in1970. The Nicks technique
facilitated placement of a larger size aortic valve prosthesis by
extending the aortotomy posteriorly through aortic sinus across the
aortic ring and inserting a patch to augment the annulus[3] .
Severe PPM according to the valve’s EOA indexed (EOAi) [severe PPM
when an EOAi <0.85
cm2/m2] is associated with worse
hemodynamic and clinical outcome [4] . PPM is a predictor of
mortality and it can be responsible for postoperative high transvalvular
PG. ARE allows for larger prosthesis implantation, consequently avoiding
PPM. Despite these potential benefits of ARE, it has not been widely
performed by cardiac surgeons, fearing of an increased risk of mortality
and morbidity [5-6-7] .
Cardiac surgeons performing AVR should be familiar with techniques of
ARE to allow insertion of appropriate-sized prosthesis in case of small
AA, and to avoid PPM. Performed properly by an experienced cardiac
surgeon, the technique is safe and reproducible [8]. So,
nowadays surgeons prefer to do ARE to get rid of PPM and to obtain
optimum hemodynamics [1-2].