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The Manouguian technique is one of the techniques used in aortic valve replacement surgery in the context of a small aortic annulus. The Manouguian technique allows for the implantation of a larger valve but requires excellent knowledge of the anatomy of the aortic outflow tract and mitral area to avoid complications. This activity reviews the indications, anatomy and physiology, and complications of the Manouguian technique and highlights the role of the interprofessional team in the care of patients that have this procedure done. Objectives: Identify the indications for the Manouguian technique. Describe the equipment, personnel, preparation, and technique in regards to the Manouguian technique. Outline the appropriate evaluation of the potential complications and their clinical significance of the Manouguian technique. Summarize interprofessional team strategies for improving care coordination and communication to enhance the Manouguian technique and improve outcomes. Access free multiple choice questions on this topic.

The Manouguian technique is a posterior aortic root enlargement technique used when the patient has a small aortic annulus and is undergoing aortic valve replacement. There are multiple aortic root enlargement techniques used to enlarge a small aortic root and outflow tract so that a larger aortic valve may be placed. The placement of a larger aortic valve allows the patient to avoid patient prosthesis mismatch (PPM) and structural valve deterioration. Implantation of a prosthetic valve of adequate size relative to the patient body surface area (BSA) can decrease the overall morbidity and mortality for the patient. The well-known postoperative complications associated with patient prosthetic mismatch have gained the attention of cardiac surgeons, so these techniques are used when a small aortic annulus with small outflow tracts is diagnosed. The Manouguian technique involves making an incision and extending it posteriorly through the commissure between the left coronary cusp and noncoronary cusp. The incision can then be carried onto the anterior mitral valve leaflet. There are multiple aortic root enlargement techniques, with the Nicks-Nunez procedure being another posterior aortic enlargement technique. The Nicks-Nunez technique involves making a vertical incision through the commissure. The incision is then carried between the left coronary cusp and noncoronary cusp all the way to the inner leaflet triangle, thus giving a larger aortic outflow tract. The Nicks-Nunez technique usually allows the placement of at least one valve size bigger. The Konno-Rastan procedure is an anterior aortic outflow tract enlargement technique. The Konno-Rastan technique involves making an incision 2 to 3 mm to the right of the anterior aortic valve commissure with an incision of the infundibular septum. When making this incision, care must be taken to not damage the conduction system or the first septal branch of the left anterior descending coronary artery. The aortic outflow tract can then be sized for a larger aortic valve. The overall goal is to recognize small aortic roots so that the best decision can be made to treat the small aortic root with an enlargement technique to avoid the associated morbidities of patient prosthesis mismatch.[1][2]

Research has shown minimal added risk when performing this technique. Patients undergoing aortic root enlargement techniques do have higher perioperative morbidity and mortality when compared to those without enlargement. However, when strictly comparing only aortic valve replacements with aortic enlargement procedures with no added operative procedures, there was no difference noted. The aortic enlargement patient group was found to have lower risks of patient prosthesis mismatch. Despite longer on pump aortic cross-clamp time, patients who underwent aortic valve replacement with aortic enlargement procedure did not experience higher rates of myocardial infarction, stroke, complete heart block/permanent pacemaker implantation, or reoperation for bleeding.[14] Infection Bleeding Damage to aortic outflow tract structures Damage to the conduction system Damage to mitral valve causing significant mitral regurgitation[15] Detachment of aortic patch[16] Dysfunction of the aortic valve if enlargement too great Patient prosthesis mismatch[5][17] Reduced exercise tolerance Delayed left ventricular regression

The Manouguian procedure has allowed for operative intervention in patients with small aortic outflow tracts and has helped to decrease patient-prosthesis-mismatch. All patients undergoing aortic valve replacement with the need for a possible root enlargement procedure should undergo preoperative discussion at interprofessional meetings to discuss complex cases. Preoperative imaging with reviewing the patient's aortic root dimensions along with their body surface area will allow the team to prepare for the possible need for aortic root enlargement and valve sizing. While a successful aortic root enlargement may decrease the overall morbidity and mortality of the patient long term, it may increase the cross-clamp and bypass times, thereby potentially increasing the perioperative morbidity and mortality of the patient. For this reason, all healthcare team members must be in constant communication and efficient in their practice to enhance better outcomes. As with any other procedure, effective preparation will enhance the healthcare team outcomes. Having a detailed plan in place, along with a preoperative discussion, will help to prevent any poor intraoperative decision making. The perfusionist and anesthesia team must be informed if longer cross-clamp times are needed to ensure adequate cardioplegia and hypothermia for the best myocardial protection. Postoperative management requires a team monitoring for many things such as post-op bleeding, arrhythmias, or other conduction issues, and pain control.

An interprofessional team is needed in order to execute every successful procedure. Cardiac surgeons perform this procedure while general anesthesia from either an anesthesiologist or a certified registered nurse anesthetist (CRNA) is provided pre and post cardiopulmonary bypass. The perfusion team maintains the patient's hemodynamics while on cardio-pulmonary bypass. The OR staff, including the nurses and scrub techs, are also very important as they assist the surgeon throughout the entire case. Postoperatively, cardiac intensivists help aid in the management of the patient's care along with cardiologists. Echo techs are available to evaluate the effectiveness of the valve through either transthoracic or transesophageal echocardiogram. Postoperatively, rehab specialists and physical therapy teams play a pivotal role in preparing the patient for discharge home. It is clear that the Manouguian procedure is one of great detail and requires precision. While there are various different roles that must be taken throughout the patients stay, interprofessional interventions and communication are vital to the success and outcomes of the patient.

Interprofessional monitoring is crucial to not only the success of the operation but to the overall outcomes of the patient's entire hospital course. To prevent any complications from occurring during the Manouguian procedure, all team members must be monitoring the patient. The anesthesia and perfusion teams are responsible for close-knit communication and keeping the patient stable throughout the procedure. This entails an adequate amount of sedation while maintaining stable perfusing vitals while on cardio-pulmonary bypass. The OR staff helps by obtaining the correct surgical supplies, prepping, positioning the patient, and helping throughout the operative case. While all team members have specific physical responsibilities, they are all responsible for monitoring the patient. Any complication may occur at any point in time. Having multiple people prepared for any event to occur helps to decrease poor outcomes.