Suture place and Valve inspection
After sizing the valve, we passed three evenly spaced sutures through
the lowest point of each valvular cusp and the prosthetic valve to
secure the prosthetic valve in the nadir of the annulus.
We always used non-pledgeted braided polyester-coated sutures with 2–0
non-cutting needles to place the three guiding sutures in the
mid-commissural nadir region of the annulus. Using pledgets may create
channels that result in PVL and could reduce the effective orifice area.
We inserted the suture from the lower end of the annulus and extracted
the inserted needle from the Valsalva wall 4 mm above the annulus.
In cases with a gap in the commissure, we placed an additional everted
mattress suture using 4–0 polypropylene monofilament sutures (Figure
2B,C). The position of the valve that we placed was 1 mm higher than the
usual recommended position to avoid postoperative arrhythmias such as
complete atrioventricular block or left bundle branch block. Again, we
did not use pledgets.
We inspected carefully before closing the aortomy. The frame must be
checked to ensure that it fits correctly into the distal LVOT. We
believe that our additional sutures are an effective way to avoid
situations in which there is a gap between the tissue under the annulus
and the prosthetic valve in the commissure .
The gap in the smaller size-mismatched patient group was corrected
entirely with the additional stitch before positioning the prosthetic
valve (Figure 2B).