**11. Summary**

*Cardiac Surgery Procedures*

and right commissure;

coronary sinuses;

described above.

**10.2 Aortic remodeling technique**

inside of the graft at this stage, so that the graft is brought over, seated and

• Prolene sutures from the tips of the commissures are then drawn through the graft at the junction of the horizontal and vertical parts of the Valsalva graft;

• Re-implantation of the aortic root is then started by suturing of the remnant of the coronary sinuses inside of the Valsalva graft. We routinely use double armed 4–0 or 5–0 Prolene and start the suture line just off the bottom of the sinus and proceeding towards the commissure between left and non-coronary sinuses bringing the stich to the top of the commissure on the outside. The other arm of the suture is then brought up the same way to the top of the left

• Similar technique is then used to re-implant the right and finally the left

• The valve is then checked for AI by filling the root with cold saline;

• Coronary buttons are then re-implanted into corresponding sinuses as

Yacoub developed his technique of creating three longitudinal neo-sinuses [56]. These are sutured to the aorta and then coronary buttons are re-implanted. This method does not protect against annular dilatation [9]. In this technique the

*The aortic remodeling technique is described. As shown, the aortic commissures are sewn to the graft, which is fashioned to form neo sinuses. Then the created tongues are sewn to the rim of the aortic wall. Coronary buttons re-implantation follows, then distal anastomosis between the graft and the ascending aorta is performed [9].*

• All three stay sutures are then tied and cut on top of the commissures followed by "working" sutures brought to the top of the corresponding commissures;

fixed over the annulus by tying the sub-annular sutures;

**46**

**Figure 6.**

Aortic root operations reflect complex anatomic relations and physiologic interactions between the left ventricle and components of the aortic root—ventriculoarterial junction (aortic annulus), sinuses of Valsalva, leaflets of the aortic valve, and sino-tubular junction. Whether a surgeon contemplates classic aortic root replacement with mechanical or tissue valve conduits or any of the valve sparing root reconstructions, close familiarity with the structure and function of the aortic root is necessary. Dreaded complications of such complex procedures (bleeding, most importantly) can be avoided by meticulous surgical technique in combination with intimate knowledge of the anatomical details of the aortic root and surrounding structures.
