Commissure and Sinus Remnant Re-Attached to Graft

A 30-millimeter tubular graft was chosen according to the sizing of aortic root. Two small notches were made to accommodate the increasing shape of right-left and the right long commissure. And sutures were evenly placed through the graft.

The commissural stained sutures were pulled out from the graft. The graft was parachuted into place and the sutures were tied. To prevent excessive narrowing of annulus, a dilator was inserted across the annulus. The proper diameter of annulus is about 24 millimeters.

Before the commissures were fixed on the graft, the graft and the commissures must be brought up so that the valve apparatus was elevated within the graft to ensure optimal leaflet cohabitation The fixing point on the three commissures in terms of height and left and right position should be adjusted precisely to ensure that perfect cohabitation of the three leaflets should be in the same plane. And the copatation center should be higher than the nadir of annulus. Once the correct positions were found, commissures were secured on the graft using mattress sutures.

Optimal leaflet cohabitation was confirmed by water flooding test. The sutures were tied on the outside of the graft and used to secure the aortic side of the scalloped annulus and the sinus remnant to the graft wall. Sinus remnant was sutured through the graft in baseball stitch fashion. The suture was successively passed from inside to outside and to the junction between aortic annulus and the remnant of sinus wall, and then from outside to inside on the graft by passing through the remnant of the sinus. Again, water was placed into the reconstructed aortic root to test the coaptation.