**6. Surgical techniques of pulmonary valve replacement**

### **6.1 Sternal re-entry**

Basics of primary or repeat sternotomy are followed. Sternal re-entry can be challenging, especially in the presence of a right-sided pathology (e.g., pulmonary hypertension, enlarged right heart structures, or extracardiac conduit). We prefer the oscillating saw for repeat sternotomy, although a craniotome can also be used.

The decision to expose the femoral vessels versus cannulating them and initiating cardiopulmonary bypass to facilitate sternotomy is individualized and is dependent on the experience of the surgeon. Groin cannulation can be performed *via* a cut down with or without percutaneous right internal jugular to superior vena cava cannulation, which allows establishing complete cardiopulmonary bypass. Special attention is made to ensure adequate antegrade perfusion and adequate venous return of the lower extremity. This may require a chimney graft on the femoral artery. Axillary artery cannulation is also an option and is preferred if concomitant aortic surgery is being performed. If it is necessary to initiate cardiopulmonary bypass before or during sternal reentry, it is important to maintain a positive central venous pressure to avoid potential air embolism, which can occur if there is inadvertent entry into the right heart in the presence of an intracardiac shunt.

The procedure can be performed with aortic and a single-venous cannulation at normothermia in the absence of concomitant cardiac pathology that needs concomitant repair. It is commonly performed on the beating heart without cardioplegic arrest in the absence of intracardiac shunts. However, a short period of aortic cross-clamping and cardioplegia may be needed in challenging cases where heavily calcified or scarred RVOT patches or conduits are present to allow safe decalcification and adequate debridement before removing the cross-clamp and completing the PVR or the new conduit placement on a beating heart.

### **6.2 Pulmonary valve reconstruction with autologous pericardium (pulmonary Ozaki)**

The basic principle of the technique in harvesting the autologous pericardium and creating the leaflets and sewing them is similar to the Ozaki technique described for aortic valve replacement.

However, there are important anatomical differences between the aortic and pulmonary roots that required modification of the technique to facilitate exposure and leaflet placement. Three possible ways to apply this technique for pulmonary valve reconstruction are as follows:


annulus/RVOT. The RVOT is enlarged with a pericardial patch in a way similar to the transannular patch technique. This patch is extended up to the future sinotubular junction, and the third leaflet is then sewn to the pericardial patch and the commissures are created followed by completing the augmentation of the main pulmonary artery with the remainder of the patch.
