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Replacement of the Ascending Aorta and Aortic Root Replacement Using a Freestyle Porcine Bioprosthesis (Inclusion Technique)

Friday, March 15, 2019

Magagna P, Piciche M, Gonzales H, Salvador L. Replacement of the Ascending Aorta and Aortic Root Replacement Using a Freestyle Porcine Bioprosthesis (Inclusion Technique). March 2019. doi:10.25373/ctsnet.7837712.

The authors illustrate the replacement of the ascending aorta and aortic valve using a Freestyle porcine bioprosthesis in a patient with a giant aneurysm of the ascending aorta (8 cm).

Procedure Details

The preoperative computed tomography angiography scan is shown in the video. The right axillary artery was cannulated with Seldinger technique, and percutaneous right femoral venous cannulation was performed for cardiopulmonary bypass. A median sternotomy was performed and aortic cross-clamp applied. The ascending aorta and the aortic valve were resected. The left and right ostia of the bioprosthesis were trimmed. A stentless aortic bioprosthesis was implanted, using polypropylene 4/0 running suture for the inflow rim. The authors begin the inflow rim suture line at the left coronary sinus, then the right coronary sinus, and finish at the noncoronary sinus. The coronary ostia are reattached using a polypropylene 4/0 suture, beginning with the left ostia.

A test was performed with a hook to check if aortic paravalvular leaks were present. The proximal anastomosis of the vascular prosthesis including both the patient ascending aorta and porcine aortic wall was performed using polypropylene 4/0 running suture, the “inclusion technique.” A second continuous suture reinforcement was performed using polypropylene 4/0 suture. The distal anastomosis was performed between the aorta and vascular prosthesis using polypropylene 4/0 running suture. The heart and vascular prosthesis were deaired and the cross-clamp removed.

The final result and postoperative echocardiography are shown in the video.


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Great video, Congratulations!! The quality, definition, the order, and the explanations are excellent as well as the case report itself. However, just a couple of questions. 1, What was the principal indication or why did you select a freestyle stentless valve instead of a regular bioprosthesis? 2. It wasn´t possible to place the arterial cannula in the arch rather than in the axillary artery? I noticed that you didn´t need to put the patient on deep hypothermia. Thank you very much, and congratulations again!
Dear dr Germán Fortunato thanks for your comment. The use of freestyle is very useful in patient with dilating the aortic root; in particular in aortic dissection; reduces bleeding and possible distortion of coronary ostia. I prefer axillary artery cannulation, where antegrade cerebral perfusion is necessary. Without the cannula in the aortic arch it is easier to work. In this case, deep hypothermia was not necessary because I did not make the circulation arrest. Thank you

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