Small body surface area and small aortic annulus always pose a challenge, especially if additional valve replacement/repair is required. Because of the anatomical position of the aortic annulus – comprised between the central fibrous body of the heart and the conus ligament of the pulmonary valve – it is pleonastic that multiple valvular annular plications may reduce the effective diameter and thus lead to an undersized aortic valve prosthesis and a severe prosthesis-patient mismatch may occur (Fig. 3).
We describe this simple and reproducible method to maintain the proper aortic diameter while suturing and fixing the mitral prosthesis.
A word of caution must be said in the case of advanced rheumatic disease causing annular calcification and stiffness; in this case we suggest to do not force the Hegar diameter above 1 mm over the valvular tester measure.
Calafiore et al. [2] described another modified sequence of valvular preparation and fixation in case of small annulus that implies the removal of both the valves and the fixation of mitral prosthesis first and then the aortic one.
We decided to fix the mitral prosthesis first while maintaining the right aortic annular shape because we found very challenging to correctly tight the valve in the antero-lateral portion of the annulus once the aortic prosthesis is placed.