Technique for Constructing Freestyle Valve-Valsalva Graft Composite Aortic Root Conduit

To begin the construction of the valve, interrupted 4-0 Ethibond sutures are used to sew the base of a freestyle subcoronary valve near the bottom collar of the Valsalva graft, anchoring the valve approximately three to four corrugations from the bottom of the graft and tying each suture after placement. This remaining skirt was used as an additional proximal hemostatic suture line at the time of the composite root replacement. 

Next, three 5-0 polypropylene sutures were used to sew the rim of aorta along the cusps of the freestyle valve to the sinus portion of the Valsalva graft. This was the primary hemostatic suture line, performed in a running mattress fashion, analogous to the David root reimplantation technique. Each suture began at the nadir of the sinus and was sewn to the commissural apex, where it could be tied. The finished conduit was then inspected.

In cases of aneurysmal disease, the most common valve size has been 29 mm, while smaller sizes such as 25 mm or 27 mm valves are used more frequently in the setting of non-aneurysmal disease such as TAVR explant, root calcification, or reoperation for patient-prosthesis mismatch.

The authors have previously published their institutional experience with this technique in over 500 patients, with excellent long-term survival and freedom from subsequent aortic valve or root replacement.

References

1. Patel PM, Callahan M, Dong A, Wei J, Binongo J, Leshnower B, Chen EP. Clinical Outcomes Using Freestyle Valve-Valsalva Graft Composite Conduit for Aortic Root Replacement. Ann Thorac Surg. 2022 Sep;114(3):643-649. doi: 10.1016/j.athoracsur.2021.12.022. Epub 2022 Jan 11. PMID: 35031292.

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