**10.1 Aortic re-implantation technique**

David and Feindel [9] recommend a technique of securing the aortic valve leaflets without the rigid synthetic graft. This technique prevents future annular dilatation. Dr. David et al. report excellent valve competence among 146 Marfan's syndrome patients with valve-sparing aortic root replacement with their technique [55] (**Figure 5**).

All preparatory steps for re-implantation procedure are similar as described above. Below are the critical steps unique for the re-implantation:


**45**

**Figure 5.**

*Aortic Root Reconstruction*

*DOI: http://dx.doi.org/10.5772/intechopen.86034*

left-to-non commissure; the nadir of the left coronary sinus; the nadir of the right coronary sinus; the right to-non commissure (avoiding membranous septum); extra sutures placed between the ones mentioned above can added in between the

*The aortic re-implantation technique is illustrated (a). As demonstrated, the entire aortic annulus, aortic valve and a rim of aortic wall are all secured inside the synthetic graft, with re-implantation of the coronary buttons* 

• Inflow edge of the Valsalva graft then marked to assure precise positioning of

• Sub annular sutures are then drawn through the graft according to the markings;

• In re-implantation procedure, instead of silk stay sutures at the tips of the commissures, we use 4–0 prolene with large needles. These stay sutures are brought

nadirs and the commissural sutures to a total of 6–9 sutures if needed;

*to the new graft (b). The distal part of the synthetic graft is anastomosed to the ascending aorta [9].*

the sub annular sutures on the vascular graft;

*Cardiac Surgery Procedures*

essential after repair.

plicating the wall of the coronary button. A second layer is then used to ensure further hemostasis. Re-implantation of the right button is performed in a similar fashion. Once the aortic root is replaced and buttons re-implanted, we

use local hemostatic glue to provide further sealing of needle holes.

replaced and attached to the proximal neo-root.

transferring the patient to the intensive care unit.

**10. Valve sparing aortic root replacement**

**10.1 Aortic re-implantation technique**

11.Then depending upon the extent of aortic dilatation, the ascending aorta is

12.Once the patient is off cardiopulmonary bypass, the right axillary artery is carefully repaired between hemostatic clamps. A good Doppler signal is

13.It is important to ensure absolute hemostasis in the operating room prior to

Sparing the patient's native aortic valve while replacing the aortic root is an alternative option in selected patients [54]. This naturally avoids need for anti-coagulation [9]. After an initial pre-operative trans-esophageal echocardiogram, the valve leaflets should be examined prior to proceeding with valve-sparing approach.

David and Feindel [9] recommend a technique of securing the aortic valve leaflets without the rigid synthetic graft. This technique prevents future annular dilatation. Dr. David et al. report excellent valve competence among 146 Marfan's syndrome patients with valve-sparing aortic root replacement with their technique [55] (**Figure 5**). All preparatory steps for re-implantation procedure are similar as described

• Once coronary buttons are prepared as described above, aortic annulus has to be dissected out so that on all sinuses the annulus can be exposed for precise placement of the sub-annular sutures. We use cautery at low settings to perform this dissection. The most difficult part of this step is to separate the root and the annulus from the RVOT. There is always a connective tissue plane between these structures which allows safe dissection down to the annulus;

• Sizing of the annulus can be done by many previously described methods. We prefer to follow a simple rule that most of the male with BSA of ~2.0–2.2 m2 should have annulus of 23–25 mm, and so 3–5 mm larger diameter of the vascular graft would be chosen (most commonly, 28 or 30 mm). For a smaller

• We prefer "Valsalva" grafts (Vascutek) which we trim on the inflow side leaving 2–3 mm (a couple of rings) of the grafts for the sub-annular sutures to be

• We then place sub-annular 2–0 ticron sutures with small pledgetes 2–3 mm below the annulus in the following order: the nadir of the non-coronary sinus; the

an annular diameter is 21–23 mm and

Leaflet quality is fundamental to event-free survival in these patients.

above. Below are the critical steps unique for the re-implantation:

female patient with a BSA of 1.8–2.0 m2

accordingly 26–28 mm grafts are usually appropriate;

**44**

drawn through;

#### **Figure 5.**

*The aortic re-implantation technique is illustrated (a). As demonstrated, the entire aortic annulus, aortic valve and a rim of aortic wall are all secured inside the synthetic graft, with re-implantation of the coronary buttons to the new graft (b). The distal part of the synthetic graft is anastomosed to the ascending aorta [9].*

left-to-non commissure; the nadir of the left coronary sinus; the nadir of the right coronary sinus; the right to-non commissure (avoiding membranous septum); extra sutures placed between the ones mentioned above can added in between the nadirs and the commissural sutures to a total of 6–9 sutures if needed;


inside of the graft at this stage, so that the graft is brought over, seated and fixed over the annulus by tying the sub-annular sutures;

