Introduction
The technique for aortic root replacement was first described in 1968 by Bentall and DeBono 1. The method was further refined and additional valve-sparing operations, such as the remodeling and reimplantation technique, were introduced later 2-3. Today, different options for aortic root replacement exist, ranging from valve sparing to valve replacing procedures. In 1967, replacement of the native aortic valve with the pulmonary valve was suggested4. Although mainly utilized in the pediatric population in the past, in recent years, it has gained more widespread acceptance in adults as well 5.
Nevertheless, all the above-mentioned techniques are surgically challenging and require a thorough understanding of the aortic root anatomy and function. There is wide variability in aortic valve phenotypes, which also affects the geometry of the aortic annulus and aortic root 6. Herein, we are describing an abnormal aortic annulus of the left coronary sinus, which was displaced into the left ventricular outflow tract (LVOT), due to aneurysmatic changes of the left coronary sinus. This occurred in the setting of a severely calcified unicuspid aortic valve in an adolescent, with extension of calcifications onto the mitral valve (Figure 1). Although the annular displacement is a subtle finding, which can easily be overlooked (Figure 2A), it has the potential for serious consequences during an aortic root replacement, when not adequately addressed. We know from Ross procedures, that distortion of the neo-aortic valve, due to a prosthetic graft alone can lead to valve dysfunction 7. This distortion can not only occur when the pulmonary autograft is seated into the prosthetic graft but can also occur when the prosthetic graft itself is distorted during placement onto the aortic annulus. We are therefore describing a surgical technique to remedy the displaced aortic annulus, through elevation of the aortic annulus to the level of the normal annulus, with a prosthetic graft in this case. This provided a geometrically balanced foundation for the pulmonary autograft, without subsequent distortion of the neo-aortic valve.