This work was supported by a grant (N&#176; 32117) of the Swiss Cardiovascular Foundation to RT.

The protocol follows the institutional guidelines of the human research ethics committee.
1. Pre-selection of the Patient
<ol>
	<li>Identify patients with dilation of the sinuses of Valsalva not exceeding 60 mm using the pre-operative computer tomography (CT) scan.</li>
	<li>Next, select among these patients a subgroup with normal or near-normal appearing aortic valve cusps on their pre-operative echocardiography.</li>
	<li>Inform the staff of the possibility of a valve sparing aortic root replacement procedure.</li>
	<li>Make the final decision intra-operatively after inspection of the aortic valve. Verify the absence of calcifications of the cusps and/or thickening and retraction of their free margin.</li>
</ol>
2. Preparation for Surgery
NOTE: Preparation for surgery follows the institutional guidelines and recommendations for adult cardiac surgery patients.
<ol>
	<li>Prepare the surgical suite and patient for surgery as previously described13.</li>
</ol>
3. Surgery
<ol>
	<li>Access to the heart through a median sternotomy, as previously described13 (Figure 1A).</li>
	<li>Prepare the aortic root for replacement.
	<ol>
		<li>Grab the ascending aorta at the sino-tubular junction with Carpentier dissection forceps. Make a horizontal opening with a #11-blade knife.</li>
		<li>Complete the aortotomy circumferentially and horizontally with Metzenbaum scissors.</li>
		<li>After having transected the aorta, verify the absence of calcifications of the cusps and/or thickening and retraction of their free margin. Check the coronary ostia.</li>
		<li>Dissect free from the surrounding tissue the outer aspect of the non-coronary sinus down to the roof of the left atrium.</li>
		<li>Detach the right coronary ostium from the aortic wall with a generous circular patch, leaving 5 mm of the aortic wall remnant attached to the insertion of the cusp (Figure 1B).</li>
		<li>Free the commissure between the non-coronary and right coronary sinus from the surrounding tissue.</li>
		<li>Dissect free the outer aspect of the aortic wall remnant of the right coronary sinus from the outflow tract of the right ventricle.</li>
		<li>Free the outer aspect of the commissure between the non-coronary and left coronary sinus down to the roof of the left atrium.</li>
		<li>Excise the aortic wall of the non-coronary sinus leaving 5 mm of the aortic wall remnant attached to the insertion of the cusp.</li>
		<li>Separate the outer aspect of the commissure between the right and left coronary sinus from the surrounding tissue. Take care not to injure the pulmonary artery.</li>
		<li>Detach the left coronary ostium from the aortic wall with a generous circular patch, leaving 5 mm of the aortic wall remnant attached to the insertion of the cusp (Figure 1B). Mobilize the left main coronary artery over its first 10 mm.</li>
		<li>Dissect free the outer aspect of the aortic wall remnant of the left coronary sinus from the roof of the left atrium.</li>
		<li>Put a mattress 4/0 polypropylene stay suture on top of each commissure.</li>
	</ol>
	</li>
	<li>Start the proximal implantation of the prosthesis.
	<ol>
		<li>Perform the first row of the proximal anastomosis by 12 mattress non-pledgeted 2/0 braided polyester sutures. Put these sutures circumferentially in a horizontal plane 1 - 2 mm below the insertion of the cusps and at the base of the commissural triangles except for the commissure between the non-coronary and right coronary sinus (Figure 2A).</li>
		<li>Put the first mattress suture at the base of the commissural triangle between the non-coronary and left coronary sinus. Put the second and third sutures 1 - 2 mm below the insertion of the non-coronary cusp, in the direction of the commissure between the non-coronary and right coronary sinus.</li>
		<li>Place the forth suture next to the third one in the direction of the commissure between the non-coronary and right coronary sinus by avoiding the base of the commissural triangle between the non-coronary and right coronary sinus and thus not compromising the membranous septum.</li>
		<li>Start the first suture of the right coronary sinus 2 mm away from the base of the commissural triangle of the commissure between the non-coronary and right coronary sinus, thus skipping the membranous septum (Figure 2B).</li>
		<li>Put the following sutures of the right coronary sinus in the direction of the commissure between the left and right coronary sinus.</li>
		<li>Place the forth suture of the right coronary sinus at the base of the commissural triangle of the commissure between the left and right coronary sinus.</li>
		<li>Next, pass 4 equidistant mattress sutures 1 - 2 mm below the insertion of the left coronary cusp for fixation of the left coronary sinus.</li>
		<li>To choose the size of the prosthesis, add 4 to 6 mm to the size of a commercially available biological valve sizer which passes comfortably through the left ventricular-aortic valve junction.</li>
		<li>Determine the commissural height between the commissural stay suture and the mattress suture at the basis of the commissural triangle. To adjust the commissural heights of the patient to the pre-shaped sinuses of the prosthesis, pass the 4/0 polypropylene commissural stay sutures inside-outside of the prosthesis in the vicinity of its sino-tubular junction.</li>
		<li>Be aware that the height of the commissure between the left and right coronary sinus is often slightly less than that of the other two. Trim circumferentially the lower neck of the prosthesis 2 mm below the measured commissural height to adapt the height of the sinuses of the prosthesis to that of the commissures and to be able to pass the first row of the mattress sutures through the prosthesis.</li>
		<li>Now pass the mattress sutures inside-out into the prosthesis. Slide down the prosthesis thus placing the valve inside it (Figure 3A). Tie the mattress sutures gently and cut them.</li>
		<li>Start the second row of the proximal anastomosis by three 5/0 polypropylene running sutures, one for each sinus.</li>
		<li>Begin the first 5/0 polypropylene running suture at the nadir of the left coronary sinus to fix the remnant of the aortic wall inside the prosthesis by following in parallel the insertion of the cusp up to the commissure between the left and right coronary and then up to the commissure between the left and non-coronary sinus. Put the 2 ends under slight tension.</li>
		<li>Continue with the second 5/0 polypropylene running suture at the nadir of the right coronary sinus to fix the remnant of the aortic wall inside the prosthesis by following in parallel the insertion of the cusp up to the commissure between the right and left coronary and then up to the commissure between the right and non-coronary sinus. Put the 2 ends under slight tension.</li>
		<li>Place the third 5/0 polypropylene running suture at the nadir of the non-coronary sinus to fix the remnant of the aortic wall inside the prosthesis by following in parallel the insertion of the cusp up to the commissure between the non-coronary and left coronary sinus.</li>
		<li>Finish the second row of the proximal anastomosis by fixing the remnant of the aortic wall in parallel to the insertion of the cusp up to the commissure between the non-coronary and right coronary sinus. Tie at each commissure the two suture-ends together (Figure 3B).</li>
		<li>Check the absence of aortic regurgitation by filling the prosthesis with saline and applying suction to the vent placed through the right pulmonary vein and the mitral valve into the left ventricle.</li>
	</ol>
	</li>
	<li>Reconnect the coronary ostia to the prosthesis (Figure 4).
	<ol>
		<li>Create a button hole in the left sinus of the prosthesis adjusted to the size of the left coronary ostium patch.</li>
		<li>Begin the anastomosis at the nadir of the button hole in the prosthesis from inside out and to the left coronary ostium from outside in by a 6/0 polypropylene running suture.</li>
		<li>Place the second stitch 2 mm to the right of the first one from inside out of the prosthesis and outside in of the left coronary ostium up to the mid-height of the right ridge of the anastomosis. Put the suture end under light tension.</li>
		<li>Continue the running suture on the left ridge of the anastomosis from outside in the prosthesis and from inside out of the left coronary ostium to meet the other end. Tie the two ends together.</li>
		<li>Create a button hole in the right sinus of the prosthesis adjusted to the size of the right coronary ostium patch.</li>
		<li>Connect the right coronary ostium to the prosthesis by a 6/0 polypropylene running suture, starting at the nadir of the right coronary ostium from inside out and into the prosthesis from outside in.</li>
		<li>Continue the suture to the mid-height of the right ridge of the anastomosis and put the end under light tension.</li>
		<li>Complete the anastomosis by running the left ridge of the anastomosis to meet the other end. Tie the two ends together.</li>
	</ol>
	</li>
	<li>Perform the distal anastomosis (Figure 4).
	<ol>
		<li>Start the anastomosis at the nadir of the distal end of the prosthesis from inside out and into the distal ascending aorta from outside in by a 5/0 polypropylene running suture. Run up the suture first to the mid-height of the right ridge of the anastomosis.</li>
		<li>Complete the distal anastomosis by running the suture on the left ridge to meet the other end. Tie the ends together.</li>
		<li>Tilt the operating table in the Trendelenburg position. Let the pump flow reduce to 50% of the full flow and slowly remove the aortic cross-clamp under gentle aspiration of the left ventricular vent.</li>
		<li>Resume the full flow of the cardio-pulmonary bypass. Check the operative field for undue surgical bleeding.</li>
		<li>Rewarm the patient to 37 &#176;C and separate the patient from the cardio-pulmonary bypass. Stabilize blood pressure, neutralize heparin by protamine infused IV in a 1:1 ratio (3 mg/kg corresponding to 300 U/kg of heparin).</li>
		<li>Check for hemostasis and put the chest drainage as needed. Close the chest in standard fashion by reapproximating the sternum with sternal wires and the soft tissue with absorbable sutures in two layers13.</li>
	</ol>
	</li>
</ol>
4. Post-operative Patient Care
<ol>
	<li>Following the transfer to the intensive care unit, provide the patient with standard post-operative care for cardiac surgical operation on aortic root13.</li>
</ol>

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J., Child, A., Radley-Smith, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Late+results+of+a+valve-preserving+operation+in+patients+with+aneurysms+of+the+ascending+aorta+and+root.">Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root.</a> J Thorac Cardiovasc Surg. 115 (5), 1080-1090 (1998).</li><li>De Paulis, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=One-year+appraisal+of+a+new+aortic+root+conduit+with+sinuses+of+Valsalva.">One-year appraisal of a new aortic root conduit with sinuses of Valsalva.</a> J Thorac Cardiovasc Surg. 123 (1), 33-39 (2002).</li><li>Rama, A., Rubin, S., Bonnet, N., Gandjbakhch, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+technique+of+aortic+root+reconstruction+with+aortic+valve+annuloplasty+in+ascending+aortic+aneurysm.">New technique of aortic root reconstruction with aortic valve annuloplasty in ascending aortic aneurysm.</a> Ann Thorac Surg. 83 (5), 1908-1910 (2007).</li><li>Richardt, D., Karluss, A., Schmidtke, C., Sievers, H. H., Scharfschwerdt, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+sinus+prosthesis+for+aortic+valve-sparing+maintaining+the+shape+of+the+root+at+systemic+pressure.">A new sinus prosthesis for aortic valve-sparing maintaining the shape of the root at systemic pressure.</a> Ann Thorac Surg. 89 (3), 943-946 (2010).</li><li>Schmidtke, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=First+clinical+results+with+the+new+sinus+prosthesis+used+for+valve-sparing+aortic+root+replacement.">First clinical results with the new sinus prosthesis used for valve-sparing aortic root replacement.</a> Eur J Cardiothorac Surg. 43 (3), 585-590 (2013).</li><li>Stamou, S. C., Williams, M. L., Gunn, T. M., Hagberg, R. C., Lobdell, K. W., Kouchoukos, N. 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(123), e55632 (2017).</li><li>Zoghbi, W. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Recommendations+for+evaluation+of+the+severity+of+native+valvular+regurgitation+with+two-dimensional+and+Doppler+echocardiography.">Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography.</a> J Am Soc Echocardiogr. 16 (7), 777-802 (2003).</li><li>Cohle, S. D., Delavan, J. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Coronary+artery+compression+by+teflon+pledget+granuloma+following+aortic+valve+replacement.">Coronary artery compression by teflon pledget granuloma following aortic valve replacement.</a> J Forensic Sci. 42 (5), 945-946 (1997).</li><li>Vallabhajosyula, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Geometric+orientation+of+the+aortic+neoroot+in+patients+with+raphed+bicuspid+aortic+valve+disease+undergoing+primary+cusp+repair+and+a+root+reimplantation+procedure.">Geometric orientation of the aortic neoroot in patients with raphed bicuspid aortic valve disease undergoing primary cusp repair and a root reimplantation procedure.</a> Eur J Cardiothorac Surg. 45 (1), 174-180 (2014).</li><li>David, T. E., David, C. M., Feindel, C. M., Manlhiot, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reimplantation+of+the+aortic+valve+at+20+years.">Reimplantation of the aortic valve at 20 years.</a> J Thorac Cardiovasc Surg. 153 (2), 232-238 (2017).</li><li>Zehr, K. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Form+ever+follows+function.">Form ever follows function.</a> J Thorac Cardiovasc Surg. 151 (1), 120-121 (2016).</li><li>De Paulis, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+of+the+valve+reimplantation+technique+using+a+graft+with+sinuses.">Long-term results of the valve reimplantation technique using a graft with sinuses.</a> J Thorac Cardiovasc Surg. 151 (1), 112-119 (2016).</li><li>Gleason, T. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=New+graft+formulation+and+modification+of+the+David+reimplantation+technique.">New graft formulation and modification of the David reimplantation technique.</a> J Thorac Cardiovasc Surg. 130 (2), 601-603 (2005).</li><li>Demers, P., Miller, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simple+modification+of+"T.+David-V"+valve-sparing+aortic+root+replacement+to+create+graft+pseudosinuses.">Simple modification of "T. David-V" valve-sparing aortic root replacement to create graft pseudosinuses.</a> Ann Thorac Surg. 78 (4), 1479-1481 (2004).</li><li>David, T. E., Maganti, M., Armstrog, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Aortic+root+aneurysm:+principles+of+repair+and+long-term+follow-up.">Aortic root aneurysm: principles of repair and long-term follow-up.</a> J Thorac Cardiovasc Surg. 140 (6S), S14-S19 (2010).</li><li>Shrestha, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Long-term+results+after+aortic+valve-sparing+operation+(David+I).">Long-term results after aortic valve-sparing operation (David I).</a> Eur J Cardiothorac Surg. 41 (1), 56-61 (2012).</li></ol>

The authors have nothing to disclose.

In patients presenting with aortic root aneurysm with normal or near-normal aortic cusps, valve-sparing aortic root replacement is a more physiological and hence attractive alternative to composite graft replacement of the aorta and the aortic valve with mechanical or tissue valve. In this protocol, we describe a simplified technique of valve-sparing aortic root replacement by re-implantation of the aortic valve. In contrast to the majority of the previously reported techniques3,<sup cl...

During the past twenty years, the surgical treatment of aortic root aneurysm with normal or near-normal aortic cusps has evolved thanks to a series of surgical procedures aiming at preservation of the native aortic valve1,2,3,4,5. Valve-sparing aortic root replacement is basically accomplished either by re-implantation of the aortic valve inside a synthetic graft1,3,4,6 or by a remodeling technique which restores the physiological anatomy of the aortic root2. Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, many cardiac surgeons replace the aortic valve with either mechanical or biological valve substitutes. According to the Society of Thoracic Surgeons database, only 14% of patients who underwent aortic root replacement in the United States between 2004 and 2010 received a valve-sparing procedure7.
In the original re-implantation technique, the aortic valve is sutured inside a tubular horizontally crimped synthetic graft8. Although this technique stabilizes the aortic annulus, it eliminates the sinuses of Valsalva. In order to recreate the sinuses of Valsalva, this technique has undergone several modifications by its inventor as well as other authors9. A variation of this technique has been proposed by Rama et al., in which the remnants of the aortic wall supporting the commissures are sutured into longitudinal openings made in the tubular polyethylene terephthalate graft4.
The remodeling technique achieves a more anatomical reconstruction of the aortic root but leaves the aortic annulus unsupported and exposed to future dilatation. Various surgical techniques have been designed to tailor the aortic annular base in aortic root remodeling, including sub-commissural aortic annuloplasty10, circumferential suture annuloplasty11, and internal or external annuloplasty by synthetic partial or complete ring12.
Despite the excellent results reported by experienced authors, the complexity and periodical modifications of these procedures hamper their reproducibility by other cardiac surgeons and thus prevent a number of suitable patients to benefit from retaining their own aortic valve. In order to enhance the reproducibility of the re-implantation technique, we have used a commercially available synthetic graft with an uncrimped, pre-shaped sinus portion and simplified the implantation technique. The aim of this protocol is to describe in detail this standardized and reproducible technique with particular emphasis on the management of the first row of the proximal suture line and of the placement of the commissures inside the graft and the choice of the graft size. Early outcomes and mid-term results are presented. Proper selection of patients for and limitations of this procedure are discussed.

<table><tbody><tr><td>&lt;strong&gt;Heart surgery infrastructure:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Heart Lung Machine</td><td>Stockert</td><td>SIII</td><td></td></tr><tr><td>EOPA 24Fr. arterial cannula</td><td>Medtronic</td><td>77624</td><td></td></tr><tr><td>Atrial caval venous cannula 34/48Fr.</td><td>Medtronic</td><td>93448</td><td></td></tr><tr><td>LV vent catheter 17Fr.</td><td>Edwards</td><td>E061</td><td></td></tr><tr><td>Antegrade 9Fr. cardioplegia cannula</td><td>Edwards</td><td>AR012V</td><td></td></tr><tr><td>Retrograde 14Fr. cardioplegia cannula&amp;nbsp;</td><td>Edwards</td><td>NPC014&amp;nbsp;</td><td></td></tr><tr><td>Coronary artery ostial cannula 90&amp;deg;</td><td>Medtronic</td><td>30155</td><td></td></tr><tr><td>Coronary artery ostial cannula 45&amp;deg;</td><td>Medtronic</td><td>30255</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>Pre-shaped sinus graft</td><td></td><td></td><td></td></tr><tr><td>Cardioroot 28 mm</td><td>Maquet</td><td>HEWROOT0028</td><td></td></tr><tr><td>Cardioroot 30 mm</td><td>Maquet</td><td>HEWROOT0030</td><td></td></tr><tr><td>Cardioroot 32 mm</td><td>Maquet</td><td>HEWROOT0032</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>Electrocautery</td><td>Covidien</td><td>Force FX</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Sutures:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Polypropylene 4/0</td><td>Ethicon</td><td>8871H</td><td></td></tr><tr><td>Polypropylene 5/0</td><td>Ethicon</td><td>8870H</td><td></td></tr><tr><td>Polypropylene 6/0</td><td>Ethicon</td><td>EH7400H</td><td></td></tr><tr><td>Braided polyesther 2/0 ligature with polybutylate coating&amp;nbsp;</td><td>Ethicon</td><td>X305H</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>Micro knife Sharpoint&amp;nbsp;</td><td>TYCO Healthcare PTY&amp;nbsp;</td><td>78-6900</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Drugs:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Midazolam</td><td>Roche Pharma</td><td>N05CD08</td><td></td></tr><tr><td>Rocuronium</td><td>MSD Merck Sharp &amp;amp; Dohme&amp;nbsp;</td><td>M03AC09</td><td></td></tr><tr><td>Propofol</td><td>Fresenius Kabi</td><td>N01AX10</td><td></td></tr><tr><td>Fentanil</td><td>Actavis</td><td>N01AH01</td><td></td></tr><tr><td>Heparin</td><td>Braun</td><td>B01AB01</td><td></td></tr><tr><td>Protamin</td><td>MEDA Pharmaceutical</td><td>V03AB14</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Instruments:&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Cooley vascular aortic clamp</td><td>Delacroix-Chevalier</td><td>DC40810-16</td><td></td></tr><tr><td>Dissection forceps Carpentier</td><td>Delacroix-Chevalier</td><td>DC13110-28&amp;nbsp;</td><td></td></tr><tr><td>Scissors Metzenbaum</td><td>Delacroix-Chevalier</td><td>B351751</td><td></td></tr><tr><td>Needle holder Ryder</td><td>Delacroix-Chevalier</td><td>DC51130-20&amp;nbsp;</td><td></td></tr><tr><td>Dissection forceps DeBakey</td><td>Delacroix-Chevalier</td><td>DC12000-21&amp;nbsp;</td><td></td></tr><tr><td>Micro needle holder Jacobson</td><td>Delacroix-Chevalier</td><td>DC50002-21&amp;nbsp;</td><td></td></tr><tr><td>Micro scisors Jacobson</td><td>Delacroix-Chevalier</td><td>DC20057-21&amp;nbsp;</td><td></td></tr><tr><td>Lung retractor</td><td>Delacroix-Chevalier</td><td>B803990</td><td></td></tr><tr><td>Allis clamp</td><td>Delacroix-Chevalier</td><td>DC45907-25&amp;nbsp;</td><td></td></tr><tr><td>O&amp;rsquo;Shaugnessy Dissector</td><td>Delacroix-Chevalier</td><td>B60650</td><td></td></tr><tr><td>18 blade knife</td><td>Delacroix-Chevalier</td><td>B130180</td><td></td></tr><tr><td>Leriche haemostatic clamp</td><td>Delacroix-Chevalier</td><td>B86555</td><td></td></tr><tr><td>&lt;strong&gt;Name&lt;/strong&gt;</td><td>&lt;strong&gt;Company&lt;/strong&gt;</td><td>&lt;strong&gt;Catalog Number&lt;/strong&gt;</td><td>&lt;strong&gt;Comments&lt;/strong&gt;</td></tr><tr><td>&lt;strong&gt;Data analysis&lt;/strong&gt;</td><td></td><td></td><td></td></tr><tr><td>Kaplan Meier curves</td><td>GraphPad</td><td>Prism 7</td><td></td></tr></tbody></table>

standardized technique of aortic valve re-implantation for valve-sparing aortic root replacement

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures prevents a number of cardiac surgeons from incorporating them into their practice. The aim of this protocol is to describe a simplified and user-friendly technique of an aortic valve-sparing root replacement (VSRR) procedure by re-implantation of the aortic valve. Proper selection of patients and limitations of the technique are discussed.
In 54 consecutive patients, normal appearing aortic valves were re-implanted in a commercially available polyester prosthesis with pre-shaped sinuses by a simplified and standardized technique. Placement of the first row of the proximal suture line, choice of the prosthesis size, and adjustment of the height of the commissures of the patient to the fixed height of the sinus portion of the prosthesis were slightly modified from the reference techniques with the aim of increasing its feasibility for use by other cardiac surgeons. Early mortality and morbidity as well as 5-year survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were collected in all patients.
Thirty-day mortality, re-sternotomy for bleeding, re-sternotomy for mediastinitis, and the incidence of stroke were very low, 1.8% for each (1 of 54). No patient required permanent pace-maker implantation. At 5 years, survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation were 97.5%, 95.2%, and 91.6%, respectively.
Mid-term results of our standardized technique of re-implantation of the aortic valve for valve-sparing aortic root replacement are very good and compare with more complex techniques reported by experienced surgeons. By following the present protocol of the standardized re-implantation technique, a greater number of cardiac surgeons can perform this procedure with comparable good results.

Statistical Analysis:
Continuous variables are presented as mean &#177; standard deviation and categorical variables as percentages. Kaplan-Meier curves are calculated for survival, freedom from aortic valve reoperation, and freedom from recurrent moderate regurgitation using a commercially available software package.
Patient Population:
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Watch this Scientific Journal Video about Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement at JoVE.com

Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Valve-sparing aortic root replacement has the advantage of preserving the patient&#39;s own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Despite the obvious advantages of the preservation of a normal aortic valve during aortic root replacement, the complexity of valve sparing procedures ...

standardized-technique-aortic-valve-re-implantation-for-valve-sparing

Research

JoVE Journal

Medicine

13.9K Views.  Hopitaux de Paris (APHP), Institut de Cardiologie. Valve-sparing aortic root replacement has the advantage of preserving the patient's own aortic valve. The complexity of the reported techniques to date restricts their use to a limited number of cardiac surgeons. This protocol describes step-by-step a standardized technique reproducible by a greater number of cardiac surgeons.

Video: Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement

Orthotopic Aortic Transplantation in Mice for the Study of Vascular Disease

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. This is largely true, but there are a number of important principles that can reduce the difficulty of these procedures and enhance reproducibility. Orthotopic aortic transplantation is an excellent procedure in which to learn these principles because it involves only two end-to-end anastomoses, but requires good suturing technique and handling of the vessels for consistent success. This procedure begins with the procurement of a length of abdominal aorta from a donor animal, followed by division of the native aorta in the recipient. The procured aorta is then placed between the divided ends of the recipient aorta and sutured into place using end-to-end anastomoses. To accomplish this objective successfully requires a high degree of concentration, good tools, a steady hand, and an appreciation of how easily the vasculature of a mouse can be damaged, resulting in thrombosis. Learning these important principles is what occupies most of the beginner's time when learning microsurgery in small rodents. Throughout this protocol, we refer to these important points. This model can be used to study vascular disease in a variety of different experimental systems1-8. In the context shown here, it is most often used for the study of post-transplant vascular disease, a common long-term complication of solid organ transplantation in which intimal hyperplasia occurs within the allograft. The primary advantage of the model is that it facilitates quantitative morphometric analyses and the transplanted vessel lies contiguous to the endogenous vessel, which can serve as an additional control9. The technique shown here is most often used for mice weighing 18-25 grams. We have accumulated most of our experience using the C57BL/6J, BALB/cJ, and C3H/HeJ strains.

We describe a technique in which a section of the abdominal aorta from a mouse is transplanted orthotopically to just below the renal arteries in an allogeneic or syngeneic recipient. This technique can be useful in studies in which transplantation of large arteries of uniform size is deemed advantageous.

Vascular procedures involving anastomoses in the mouse are generally thought to be difficult and highly dependent on the skill of the individual surgeon. ...

A New Murine Model of Endovascular Aortic Aneurysm Repair

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of Abdominal aortic aneurysm (AAA) pathophysiology. There is no abdominal aortic aneurysm endograft exclusion model cheap and reproducible, which would allow deep investigations of AAA before and after treatment. We hereby describe how to induce, and then to exclude with a covered coronary stentgraft an abdominal aortic aneurysm in a rat. The well known elastase induced AAA model was first reported in 19901 in a rat, then described in mice2. Elastin degradation leads to dilation of the aorta with inflammatory infiltration of the abdominal wall and intra luminal thrombus, matching with human AAA. Endovascular exclusion with small covered stentgraft is then performed, excluding any interactions between circulating blood and the aneurysm thrombus. Appropriate exclusion and stentgraft patency is confirmed before euthanasia by an angiography thought the left carotid artery. Partial control of elastase diffusion makes aneurysm shape different for each animal. It is difficult to create an aneurysm, which will allow an appropriate length of aorta below the aneurysm for an easy stentgraft introduction, and with adequate proximal and distal neck to prevent endoleaks. Lots of failure can result to stentgraft introduction which sometimes lead to aorta tear with pain and troubles to stitch it, and endothelial damage with post op aorta thrombosis. Giving aspirin to rats before stentgraft implantation decreases failure rate without major hemorrhage. Clamping time activates neutrophils, endothelium and platelets, and may interfere with biological analysis.

Histological and biochemical modifications after aneurysm endograft exclusion are still unclear. We describe a new model of endograft implantation on a murine aneurysm. Through thrombus analysis with and without persistant circulating blood stream interface, and new endovascular biomaterials evaluation, this model will help to better understand endovascular aneurysm exclusion pathobiology.

Endovascular aneurysm exclusion is a validated technique to prevent aneurysm rupture. Long-term results highlight technique limitations and new aspects of ...

Using the Sleeve Technique in a Mouse Model of Aortic Transplantation - An Instructional Video

Orthotopic aortic transplantation using the sleeve technique reduces injury to the aorta with failure rate of only 10-20%. The time to anastomose the aorta in mice using the sleeve method was short and easy averaging 20 min, permitting studies of iso/allo grafts. The following article describes the aortic transplantation procedure used in our laboratory. The mice were anesthetized with a mixture of 1.5% volume isoflurane and 100% oxygen through a face mask. At this point, the segment of the aorta between the renal arteries and its bifurcation was separated from the vena cava, freely prepared and clampedat the proximal and distal segments with a single silk suture. Prior to the removal of the aorta, a saline solution containing heparin was injected into the inferior vena cava. Then the aorta was cut between the clamps and a saline heparin solution was used to flush the lumen. The sleeve technique with monofilament sutures was used in order to transplant the abdominal aorta in the orthotopic position.

We present an orthotopic aortic transplantation model using the sleeve technique in mice. It is a very rapid anastomosis method, which can be employed in studies of vascular disease.

Orthotopic aortic transplantation using the sleeve technique reduces injury to the aorta with failure rate of only 10-20%. The time to anastomose the ...

Minimally Invasive Transverse Aortic Constriction in Mice

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard open-chest transverse aortic constriction (TAC). Although transverse aortic constriction is a highly functional method for the induction of high pressure in the left ventricle, it is a more difficult and lengthy procedure due to its use of artificial ventilation with tracheal intubation. TAC is oftentimes also less survivable, as the newer method, MTAC, neither requires the cutting of the ribs and intercostal muscles nor tracheal intubation with a ventilation setup. In MTAC, as opposed to a thoracotomy to access to the chest cavity, the aortic arch is reached through a midline incision in the anterior neck. The thyroid is pulled back to reveal the sternal notch. The sternum is subsequently cut down to the second rib level, and the aortic arch is reached simply by separating the connective tissues and thymus. From there, a suture can be wrapped around the arch and tied with a spacer, and then the sternal cut and skin can be closed. MTAC is a much faster and less invasive way to induce left ventricular hypertension and enables the possibility for high-throughput studies. The success of the constriction can be verified using high-frequency trans-thoracic echocardiography, particularly color Doppler and pulsed-wave Doppler, to determine the flow velocities of the aortic arch and left and right carotid arteries, the dimension of the blood vessels, and the left ventricular function and morphology. A successful constriction will also trigger significant histopathological changes, such as cardiac muscle cell hypertrophy with interstitial and perivascular fibrosis. Here, the procedure of MTAC is described, demonstrating how the resulting flow changes in the carotid arteries can be examined with echocardiography, gross morphology, and histopathological changes in the heart.

Minimally invasive transverse aortic constriction (MTAC) conserves the essentials of regular transverse aortic constriction (TAC) while eliminating the use of a ventilator with tracheal intubation. It proves to be a highly desirable method for high-throughput studies on left ventricular overload, particularly in translational studies.

Minimally invasive transverse aortic constriction (MTAC) is a more desirable method for the constriction of the transverse aorta in mice than standard ...

Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial valve might not meet the functional needs. The implantation of a too-small stented pericardial valve, leading to an effective orifice area indexed to a body surface area less than 0.85 cm2/m2, is regarded as prosthesis-patient mismatch (PPM). A PPM negatively affects the regression of left ventricular hypertrophy and thus the normalization of left ventricular function and the alleviation of symptoms. Persistent left ventricular hypertrophy is associated with an increased risk of arrhythmias and sudden cardiac death. In the case of predictable PPM, there are three options: 1) accept the PPM resulting from the implantation of a stented pericardial valve when comorbidities of the patient forbid the more technically demanding operative technique of implanting a larger prosthesis, 2) enlarge the aortic root to accommodate a larger stented valve substitute, or 3) implant a stentless biological valve or a homograft. Compared to classical aortic valve replacement with stented pericardial valves, the full-root implantation of stentless aortic xenografts offers the possibility of implanting a 3-4 mm larger valve in a given patient, thus allowing significant reduction in transvalvular gradients. However, a number of cardiac surgeons are reluctant to transform a classical aortic valve replacement with stented pericardial valves into the more technically challenging full-root implantation of stentless aortic xenografts. Given the potential hemodynamic advantages of stentless aortic xenografts, we have adopted full-root implantation to avoid PPM in patients with small aortic roots necessitating an aortic valve replacement. Here, we describe in detail a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses. Limitations of this technique and alternative options are discussed.

Full-root aortic valve replacement by stentless aortic xenograft is a viable option in patients with small aortic roots. We describe, a technique for the full-root implantation of stentless aortic xenografts, with emphasis on the management of the proximal suture line and coronary anastomoses, and discuss its limitations and alternative options.

In patients with small aortic roots who need an aortic valve replacement with biological valve substitutes, the implantation of the stented pericardial ...

Technique and Patient Selection Criteria of Right Anterior Mini-Thoracotomy for Minimal Access Aortic Valve Replacement

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The incidence of the pathology increases with growing age after 65 years. Conventional surgical aortic valve replacement through median sternotomy has been the gold standard of patient care for symptomatic aortic valve stenosis. However, as the risk profile of patients worsens, other therapeutic strategies have been introduced in an attempt to maintain the excellent results obtained by the established surgical treatment. One of these approaches is represented by transcatheter aortic valve implantation. Although the outcomes of high-risk patients undergoing treatment for symptomatic aortic valve stenosis have improved with transcatheter aortic valve replacement, many patients with this condition remain candidates for surgical aortic valve replacement. In order to reduce the surgical trauma in patients who are candidates for surgical aortic valve replacement, minimally invasive approaches have garnered interest during the past decade. Since the introduction of right anterior thoracotomy for aortic valve replacement in 1993, right anterior mini-thoracotomy and upper hemi-sternotomy have become the predominant incisional approaches among cardiac surgeons performing minimal access aortic valve replacement. Beside the location of the incision, the arterial cannulation site represents the second major landmark of minimal access techniques for aortic valve replacement. The two most frequently used arterial cannulation sites include central aortic and peripheral femoral approaches. With the purpose of reducing surgical trauma in these patients, we have opted for a right anterior mini-thoracotomy approach with a central aortic cannulation site. This protocol describes in detail a technique for minimally invasive aortic valve replacement and provides recommendations for patient selection criteria, including cardiac computer tomography measurements. The indications and limitations of this technique, as well as its alternatives, are discussed.

The goal of this protocol is to describe in detail the technique of minimally invasive aortic valve replacement through a right anterior mini-thoracotomy and central aortic cannulation. This technique can potentially enhance patients&#39; comfort and, by reducing post-operative morbidity, promote lowering the length of stay and global costs.

Aortic valve stenosis has become the most prevalent valvular heart disease in developed countries, and is due to the aging of these populations. The ...

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

Transcatheter Pulmonary Valve Replacement from Autologous Pericardium with a Self-Expandable Nitinol Stent in an Adult Sheep Model

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow tract or bioprosthetic valve dysfunction, with excellent early and late clinical outcomes. However, clinical challenges such as stented heart valve deterioration, coronary occlusion, endocarditis, and other complications must be addressed for lifetime application, particularly in pediatric patients. To facilitate the development of a lifelong solution for patients, transcatheter autologous pulmonary valve replacement was performed in an adult sheep model. The autologous pericardium was harvested from the sheep via left anterolateral minithoracotomy under general anesthesia with ventilation. The pericardium was placed on a 3D shaping heart valve model for non-toxic cross-linking for 2 days and 21 h. Intracardiac echocardiography (ICE) and angiography were performed to assess the position, morphology, function, and dimensions of the native pulmonary valve (NPV). After trimming, the crosslinked pericardium was sewn onto a self-expandable Nitinol stent and crimped into a self-designed delivery system. The autologous pulmonary valve (APV) was implanted at the NPV position via left jugular vein catheterization. ICE and angiography were repeated to evaluate the position, morphology, function, and dimensions of the APV. An APV was successfully implanted in&#160;sheep J. In this paper, sheep J was selected to obtain representative results. A 30 mm APV with a Nitinol stent was accurately implanted at the NPV position without any significant hemodynamic change. There was no paravalvular leak, no new pulmonary valve insufficiency, or stented pulmonary valve migration. This study demonstrated the feasibility and safety, in a long-time follow-up, of developing an APV for implantation at the NPV position with a self-expandable Nitinol stent via jugular vein catheterization in an adult sheep model.

This study demonstrates the feasibility and safety of developing an autologous pulmonary valve for implantation at the native pulmonary valve position by using a self-expandable Nitinol stent in an adult sheep model. This is a step toward developing transcatheter pulmonary valve replacement for patients with right ventricular outflow tract dysfunction.

Transcatheter pulmonary valve replacement has been established as a viable alternative approach for patients suffering from right ventricular outflow ...

A Modified Technique for Transverse Aortic Constriction in Mice

Transverse aortic constriction (TAC) is a frequently used surgery in research regarding heart failure and cardiac hypertrophy based on the formation of pressure overload in mouse models. The main challenge of this procedure is to clearly visualize the transverse aortic arch and precisely band the target vessel. Classical approaches perform a partial thoracotomy to expose the transverse aortic arch. However, it is an open-chest model that causes a rather large surgical trauma and requires a ventilator during the surgery. To prevent unnecessary trauma and simplify the operating procedure, the aortic arch is approached via the proximal proportion of the sternum, reaching and binding the target vessel using a small self-made retractor that contains a snare. This procedure can be conducted without entering the pleura cavity and does not need a ventilator or microsurgical operation, which leaves the mice with physiological breathing patterns, simplifies the procedure, and significantly reduces operation time. Due to the less invasive approach and less operation time, mice can undergo fewer stress reactions and recover rapidly.

The present protocol describes a modified and simplified technique with a minimally invasive transverse aortic constriction (TAC) procedure using a self-made retractor. This procedure can be conducted without a ventilator or microscope and introduces pressure overload, eventually leading to cardiac hypertrophy or heart failure.

Transverse aortic constriction (TAC) is a frequently used surgery in research regarding heart failure and cardiac hypertrophy based on the formation of ...

Biology

Novel and Innovative Hybrid Technique for Type A Aortic Dissection

Acute Stanford type A aortic dissection (TAAD) is a surgical emergency characterized by a high mortality rate and numerous complications. In the treatment of TAAD, the timing of surgery and the choice of surgical procedure are of paramount importance. Open total aortic arch reconstruction remains the gold standard for aortic arch surgery and is one of the most challenging procedures. However, this approach is invasive, relatively lengthy, and associated with substantial bleeding, which necessitates high levels of operator skill and carries the risk of multiple complications, particularly neurological ones. This report describes a novel hybrid procedure named Open Ascending Aorta Replacement Combined with Fenestrated Total Aortic Arch Stenting. A case was selected in which the lesion did not involve the aortic arch, at least on the greater curvature side of the arch. Ascending aortic replacement was performed, followed by arch intervention with self-modified stent grafts to preserve the aortic arch native branches. This approach allows for a rapid simplification of the procedure, avoids deep hypothermia or circulatory arrest associated with conventional open surgery, and mitigates neurological complications.

The protocol describes ascending aortic replacement combined with endovascular coverage of the entire aortic arch with a fenestrated stent graft in a patient with acute type A aortic dissection in the absence of a tear in the aortic arch.

Acute Stanford type A aortic dissection (TAAD) is a surgical emergency characterized by a high mortality rate and numerous complications. In the treatment ...