Strategic aortic root enlargement for patients with a small aortic annulus in the era of transcatheter aortic valve-in-surgical aortic valve procedures.

Transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV) is central to lifetime aortic stenosis management, making the initial surgery in small annuli increasingly important. In bioprosthetic surgical aortic valve replacement (AVR), surgeons must balance minimally invasive access, avoid prosthesis-patient mismatch, and prepare for future transcatheter reinterventions. We describe a sternum-sparing, minimally invasive AVR program using the Stonehenge technique with a TAV-in-SAV-oriented strategy for annular and root enlargement. Although Y-incision enlargement allows for valve upsizing, the geometry may remain unfavorable without adequate sinotubular junction (STJ) expansion, increasing the risk of sinus sequestration and coronary obstruction despite acceptable virtual valve-to-coronary (VTC) distances. We added STJ enlargement using the roof technique to achieve an en bloc expansion of the annulus, sinuses, STJ, and proximal ascending aorta. CT analyses and simulations showed that prosthesis tilt can shorten the VTC, especially in the right coronary artery (RCA), recreating a high-risk anatomy. STJ enlargement with tilt minimization may improve future TAV-in-SAV feasibility while preserving the surgical AVR benefits.