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.