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].