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).