Technique
The surgical technique is illustrated in the Video (Video 1,
supplementary material). After excision of a severely calcified
unicuspid valve and debridement of aortomitral curtain calcifications
(Figure 1), we noticed the asymmetric aortic annulus with significant
displacement of the left coronary aortic annulus into the LVOT (Figure
2A). The leftover graft of a 28mm Cardioroot graft (Getinge, Sweden),
which was used for pulmonary autograft reinforcement, was sewn to the
aortic annulus of the left coronary sinus with a 4.0 Prolene suture
(Figure 2B). The autograft reinforcement technique has been previously
described in detail 7. The graft was sewn to the
aortic annulus effectively from the left/right- coronary commissure to
the non/left- coronary commissure. During the surgery, we started the
suture line in the middle of the sinus (Figure 2B) and completed the
suture line on the displaced annulus and towards each commissure. Once
the graft was seated and tied, it was cut and the free margin of the
graft was trimmed to align with the height of the normal annulus of the
non- and right coronary sinus (Figure 2C). An additional commissural
stitch was placed at each commissure to secure the graft at the 2
lateral edges (Figure 2D). Upon completion of this step, a balanced
aortic annulus was created with an even horizontal plane (Figure 3A),
which would match the horizontal plane of the graft reinforced autograft
(Video 1).
The pulmonary autograft was then sewn to the neo-aortic annulus with a
running 4.0 Prolene suture (Figure 3B,C). This allowed for seating of
the pulmonary autograft to an even and horizontally balanced aortic
annulus, without any graft or neo-aortic valve distortion (Figure 3D).