Early and late outcomes of surgical aortic valve replacement with or without aortic annular enlargement in patients with small aortic annulus: an exploratory comparison of Y-incision versus Manouguian techniques.

Background: Whether aortic annular enlargement (AAE) improves outcomes during surgical aortic valve replacement (SAVR) in patients with small aortic annulus (SAA) remains unclear. This study compared early and late outcomes of SAVR with or without AAE and evaluated the Y-incision versus Manouguian techniques. Methods: We retrospectively analyzed 255 patients with SAA undergoing SAVR between January 2013 and March 2025. The cohort was classified into patients receiving isolated SAVR (AVR group, n=187) or SAVR with AAE (AVR + AAE group, n=68), with the latter further stratified by technique into the Manouguian (n=37) and Y-incision (n=31) subgroups. Propensity score matching (PSM) was performed. Survival was assessed using Kaplan-Meier analysis, and readmission and reoperation were evaluated using Fine-Gray competing risk models. Results: After matching, all baseline demographics, comorbidities, and surgical indications were comparable between the groups. The AVR + AAE group had longer cardiopulmonary bypass time and cross-clamp time but received larger prostheses with higher effective orifice area index (EOAI) and lower rates of moderate-to-severe prosthesis-patient mismatch (PPM), demonstrating superior hemodynamics across all follow-ups. Despite longer intensive care unit stays and higher rates of prolonged ventilation, reintubation, and dialysis-requiring acute kidney injury, 30-day mortality and 5-year survival were comparable (95.6% Conclusions: AAE should be considered during SAVR for SAA patients to optimize valve hemodynamics and reduce readmissions. The Y-incision provides greater annular enlargement and hemodynamic benefits than the Manouguian technique, supporting its wider application in clinical practice.