The Trap-Door Technique in Adult Cardiac Surgery

Coronary ostia re-implantation is a key stage of aortic root replacement. Currently, the button technique is the most widespread method, and is considered the standard approach. However, there are still concerns about the incidence of coronary pseudoaneurysm formation, bleeding, and distortion of the coronary geometry, especially when the coronaries are hard to mobilize (as in re-operations or when the coronaries are too far from the neo-aortic root).

The authors have adapted the trap-door technique, commonly used in the arterial switch operation in children, in order to re-implant the coronary ostia in adult patients undergoing aortic root replacement. To implant the coronary ostium, an L-shaped trap-door flap is created at the correct height and radial position in the conduit graft. The flap is medially hinged, with the apex of a 90-degree corner directed toward the annulus. This technique creates a cone-like extension of the conduit graft, from which the coronary ostium arises. The wide range of mobility given to the coronaries with this technique prevents coronary distortion and reduces tension on the sutures. When conventional re-implantation techniques are not feasible, this method could be considered as an alternative to avoid the use of an interposition vascular graft or a pericardial patch.