Valve-Sparing Aortic Root Replacement Using the Reimplantation Technique

The aorta was cross-clamped, and the heart was arrested using antegrade cardioplegia. The aorta was transected and trimmed to the sinotubular junction. Commissural pledgeted stay sutures were placed, and the valve was carefully assessed. Once the valve was deemed suitable for preservation, the graft was sized using a Hegar dilator and measurement of the interleaflet triangle height. The coronary buttons were prepared in a standard fashion, leaving 6 mm of native aortic sinus tissue. The aortic root was dissected circumferentially and low enough to prevent impingement of the leaflets by the subannular sutures. Six subannular sutures were placed—one below each commissure and one below the nadir of each sinus. The subannular suture below the right noncommissure was offset toward the right to avoid conduction tissue. Excess sinus tissue was resected. A Valsalva graft was prepared and anchored to the root, with commissures suspended on the graft. A hemostatic suture line was performed using two arms of a double-armed 4-0 Prolene suture in a simple running fashion starting from the inside of the graft at the bottom of the sinus and running along the commissure post toward the top of the graft. Coronaries were reimplanted using a running 5-0 Prolene suture, starting with the left coronary button (using imbrication for the back wall of this anastomosis) and completing the right coronary button. Finally, the distal graft anastomosis was performed. Throughout the operation, the valve leaflets were repeatedly assessed for symmetry, prolapse, coaptation, height, and overall competence. 

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