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Valve-Sparing Aortic Root Replacement Using the Remodeling Technique With Aortic Annuloplasty: Bicuspid Valves With Repair of Specific Lesion Sets: How I Teach It

2019; Elsevier BV; Volume: 108; Issue: 2 Linguagem: Inglês

10.1016/j.athoracsur.2019.05.011

1552-6259

Pouya Youssefi, Pavel Žáček, Mathieu Debauchez, Emmanuel Lansac,

Aortic aneurysm repair treatments

Dr Lansac discloses a financial relationship with Coroneo, Inc.The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.05.011] on http://www.annalsthoracicsurgery.org. Dr Lansac discloses a financial relationship with Coroneo, Inc. The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.05.011] on http://www.annalsthoracicsurgery.org. Bicuspid aortic valve (BAV) affects 1% to 2% of the general population1Ward C. Clinical significance of the bicuspid aortic valve.Heart. 2000; 83: 81-85Google Scholar and is often associated with early valve degeneration leading to aortic insufficiency (AI) or stenosis. Along with this valvulopathy, aortopathy is often present, with the aortic root and ascending aorta commonly dilated.2Nistri S. Sorbo M.D. Marin M. Palisi M. Scognamiglio R. Thiene G. Aortic root dilatation in young men with normally functioning bicuspid aortic valves.Heart. 1999; 82: 19-22Google Scholar A study of prevalence showed aortic dilatation in 56% of those younger than 30 years and up to 88% of those older than 80 years,3Della Corte A. Bancone C. Quarto C. et al.Predictors of ascending aortic dilatation with bicuspid aortic valve: a wide spectrum of disease expression.Eur J Cardiothorac Surg. 2007; 31 ([discussion 404-405]): 397-404Google Scholar with root dilatation being more prevalent in the presence of AI. Although in the past a root aneurysm with regurgitant BAV would have been treated with a mechanical Bentall procedure, there has been a recent interest in applying techniques of aortic valve preservation in reconstructing the root and repairing the BAV. The results of the mechanical Bentall procedure have shown higher long-term mortality than expected.4Mookhoek A. Korteland N.M. Arabkhani B. et al.Bentall procedure: a systematic review and meta-analysis.Ann Thorac Surg. 2016; 101: 1684-1689Google Scholar In addition to this, long-term disadvantages of anticoagulation, thromboembolism, and endocarditis exist with mechanical prostheses. Valve-sparing root replacement (VSRR) procedures that were initially introduced in the early 1990s, along with more recently standardized techniques of aortic valve repair, allow for reconstruction of the aortic root and cusps to restore the normal geometry and competence of the valve. Risk factors for repair failure or recurrence of AI can involve elements such as an untreated dilated annulus (> 25-28 mm) and residual cusp prolapse (native prolapse or induced prolapse after root reconstruction). To develop a technique that is both reproducible and produces high-quality long-term outcomes, we have developed a standardized aortic valve repair approach that addresses the annulus, the aorta, and the valve cusps. This involves a physiological reconstruction of the aortic root according to the remodeling technique, cusp effective height (eH) resuspension, and a subvalvular external aortic ring annuloplasty.5Lansac E. Di Centa I. Raoux F. et al.An expansible aortic ring for a physiological approach to conservative aortic valve surgery.J Thorac Cardiovasc Surg. 2009; 138: 718-724Google Scholar In 1983, Yacoub6Yacoub M. Fagan A. Stassano P. Radley-Smith R. Results of valve conserving operations for aortic regurgitation.Circulation. 1983; S3: 321Google Scholar, 7Sarsam M.A. Yacoub M. Remodeling of the aortic valve anulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438Google Scholar described the remodeling technique that involved replacing the diseased sinuses of Valsalva with tongue-shaped extensions of a vascular graft. This maintains the sinus shape of the root, as well as the aortic valve leaflets, their hinges, interleaflet triangles, and commissures. In the case of BAV, we reconstruct 2 symmetrical neosinuses with the use of tongue-shaped extensions of the vascular graft, providing physiological cusp movement and preserving root expansibility through the interleaflet triangles. We combine this with a subvalvular expansible external ring annuloplasty (to reduce the annulus, increase cusp coaptation height, and restore the ratio between the sinotubular junction [STJ] and the annulus), as well as leaflet repair and resuspension of cusp eH. In BAV root aneurysms, we have achieved a 10-year freedom from valve-related reoperation, AI grade 3 or higher, and major adverse valve-related events of 100%, 100%, and 98.2%, respectively.8Lansac E. Di Centa I. Sleilaty G. et al.Remodeling root repair with an external aortic ring annuloplasty.J Thorac Cardiovasc Surg. 2017; 153: 1033-1042Google Scholar For the surgeon to be able to competently perform a VSRR along with valve repair, it is important for them to have a systematic approach with a structure in place for the steps of the operation. We have developed a standardized technique for aortic root repair that we have taught at an international level. This technique has progressed and advanced over the years, with each element being evidence based. This is the second article of 4 in the series, which are deep-dives into how we teach our standardized techniques of aortic root and valve repair, including valve-sparing root replacement in tricuspid aortic valves (TAVs) and BAVs, as well as isolated repair of tricuspid and bicuspid valves (Figure 1). Previously, we have described root remodeling and annuloplasty in TAV.9Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Google Scholar In this second article, we describe our approach to teaching valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty in BAVs. Reconstructing the root and repairing the valve in BAV requires slightly different considerations to the case of TAV. We describe teaching of the standardized technique for both straightforward cases and for specific valve lesion sets. Before embarking on learning advanced techniques of aortic root repair, the trainee must have undertaken generalized training in operative cardiac surgery, having performed a number of composite aortic root replacements as primary surgeon. The trainee must be able to demonstrate knowledge of aortic root anatomy and the pathophysiology of aortic valve disease and aortopathy. From early on in their training in aortic root and valve repair, trainees are taught the basic framework for the surgical approach to AI according to aorta phenotype (Figure 1). From the size of the sinuses of Valsalva and/or the ascending aorta (ie, whether ≥ 45 mm), the decision to undertake either VSRR (remodeling technique), tubular aorta replacement, or isolated aortic valve repair (with double subvalvular and supravalvular annuloplasty) is made. In each of these 3 scenarios, we undertake subvalvular annuloplasty if the annulus is 25 mm or more and systematic eH resuspension, as described. To be exposed to an adequate volume of these different operations, a unit with a high volume for aortic surgery and AI is required. Further to our international course on aortic valve and root repair, there are currently a number of other worldwide courses that use both live cases and wetlabs for the delegates. We encourage our trainees to attend these courses to learn from the different schools of aortic valve repair. One of the most important facets of aortic valve and root repair is the imaging assessment of the aortic root. This involves both echocardiography and gated computed tomography (CT)/magnetic resonance imaging (MRI) (Video 1). The trainee is exposed to a high volume of echocardiograms and gated CT/magnetic resonance imaging and in time must learn to use the results of these to suggest preliminary operative plans for the patient. We teach a standardized series of steps that provides a framework for the operation. The order of the steps follows a logical purpose: (1) excision of sinuses and dissection down to the subvalvular plane; (2) valve assessment, including inspection, geometric height measurement of the non-fused cusp, annulus diameter, commissural assessment of fenestrations and angle, and raphe assessment of cusp mobility; (3) sizing of aortic graft and external annuloplasty ring; (4) subvalvular U sutures; (5) alignment of cusp free edges; (6) root remodeling with 2 symmetrical sinuses; (7) eH measurement and cusp resuspension; (8) subvalvular ring implantation; (9) coronary reimplantation; and (10) distal aortic anastomosis. The trainee must first learn and demonstrate all the steps of the procedure while assisting, before being helped to perform the procedures themselves. The supine position is adopted for the operation. A sandbag is used under the shoulder to bring up the aortic root and ascending aorta for better exposure. We perform a limited skin incision with median sternotomy or a mini-J sternotomy (into the third left intercostal space), because exposure of the aortic root and ascending aorta can be achieved satisfactorily with these approaches. Systemic heparinization with arterial cannulation of the aortic arch and venous cannulation of the right atrium is our standard approach to cardiopulmonary bypass, although peripheral cannulation can also be used for the minimally invasive approach. The trainee is taught to expose the aortic arch and cannulate high up beyond the innominate artery to be able to clamp as distally as possible and to excise as much of the ascending aorta as possible. A right superior pulmonary vein vent is used to improve drainage and exposure. If the patient has an aortic root aneurysm with a competent BAV and no AI, then root cardioplegia can be administered. If there is AI, as is the case in most patients, direct antegrade ostial cardioplegia is given. The aorta is transected fully 2 cm proximal to the cross-clamp (to prepare for distal aortic anastomosis later), and direct cardioplegia is given into the coronary ostia, using Custodiol HTK cardioplegia solution (Essential Pharmaceuticals LLC, Durham, NC) for 7 minutes. In the following steps, we describe the operation for a BAV root aneurysm with fusion of the right and left coronary cusps, the commonest configuration for BAVs. Later in the section "Specific Lesion Sets," we describe the different considerations for a right-non fusion BAV. A full assessment of the valve cusps is reserved for after the root has been dissected and excised, because the commissures and cusps can be manipulated more easily after excision of the sinuses. However, a brief inspection is performed at this stage to ensure no obvious contraindications exist to repair (such as gross calcification or multiple ruptured fenestrations that affect both leaflets). Furthermore, the height of the commissures and raphes must be assessed at this stage. The trainee is taught to consider a fused raphe as an underdeveloped commissure. Therefore the height of the raphe will be lower than the height of the commissures. The trainee must carefully assess the height of all commissures and raphes, because it can be easy to miss a minor form of unicuspid valve in which a second raphe is present and consequently 2 of the commissures are lower in height than the third true commissure. The root is dissected down to the subvalvular level. This deep dissection is one of the earliest parts of the operation that trainees perform. Although challenging, it is important for trainees to perform this as much as possible during their training. A number of important anatomic structures surround the aortic root, particularly at the subvalvular level, and it is important for the trainee to learn how to avoid damage to these during their dissection. We perform this dissection using cautery, at the same setting as used for internal mammary harvest. It can also be performed with the use of scissors. The trainee must dissect down below the level of the nadir of the 2 cusps. First, dissection is performed around the non-coronary non-fused sinus (the easiest part of the dissection), then followed by the left hemi-sinus of the fused cusp, and then finally the right hemi-sinus of the fused cusp. Around the non-coronary sinus, the plane between the roof of the left atrium and the aortic wall is dissected until it is freed to a level that is below the nadir of the non-coronary cusp. Now, the non-coronary sinus is excised, leaving a 3-mm rim of aortic tissue from the hinge-point of the non-coronary cusp. At the 2 commissures, the aorta is excused 3 to 5 mm above each commissure. A 5-0 polypropylene suture is place 1 mm above each commissure. This is placed on a protected clip, because it will be used later for suturing the remodeling graft. The plane between the left hemi-sinus (of the fused right–left sinus) and the pulmonary artery (PA) is tackled next. To avoid cutting through the aorta and entering the sinus or the left ventricular outflow tract, the trainee is taught to dissect in a tangential manner between the left hemi-sinus and the PA, tangentially away from the aorta. The aortopulmonary ligament must be divided to reach the subvalvular plane. The plane of dissection can be fatty, and it is important to keep dissecting deeper until no further fat is seen and only muscle is reached. For the deepest parts of the hemi-left and for all of the hemi-right dissection, the fused sinus must be excised (leaving a 3-mm rim of aortic tissue), and both the left and right coronary buttons are prepared. In BAV, the coronary ostia can often be close to the 2 commissures, and care must be taken to leave enough aortic rim to suture the remodeling graft, but without cutting too close to the coronary ostia. The coronary buttons should not be mobilized to not cause kinking of the coronaries. Once the right coronary button has been excised, the plane between the right hemi-sinus and the right ventricle (RV)/infundibulum is dissected deeper. In this area, the trainee is taught to no longer dissect tangentially away from the sinus, but to dissect close to the aortic wall vertically down. Straying away from the aortic wall here will inevitably lead to entering the infundibulum. This area of dissection is typically the most demanding for the trainee. The trainee learns to routinely clamp the venous line after the root dissection to check for any bleeding from the RV/infundibulum or PA, which can be easily repaired at this stage of the operation. If needed, repair is usually performed with 5-0 or 6-0 polypropylene sutures with pericardial pledgets. At the right non-commissure, the membranous septum limits the dissection plane, and the base of the right non-interleaflet triangle corresponds externally to the insertion of the membranous septum, infundibulum, right atrium wall, and septal leaflet of the tricuspid valve. The trainee is encouraged to use scissors to dissect in this region to avoid burn injury to the bundle of His (Video 2). Once the sinuses have been excised, it is easier to manipulate the commissures and leaflets and to perform a full valve assessment. Trainees are encouraged to make an assessment of the valve and report their findings. The morphologic characteristics of the BAV are examined, and the cusps are inspected for tissue quality and leaflet mobility. In the case of a type I BAV, the raphe is inspected for thickness and its effect on cusp mobility. The commissures are assessed to look for a minor form of unicuspid valve with a second raphe. Fenestrations are examined to decide which are small and physiological (and thus left alone) and those which are involved in the mechanism of AI and/or large and ruptured that require repair. Areas of calcification are examined. A ruler is used to measure the geometric height of the non-fused cusp. This is done by grasping the nodule of Arantius carefully with forceps and gently stretching the non-fused cusp while the assistant is stretching on the 2 commissures, to measure from the nadir of the cusp to the free edge. In BAVs, the non-fused cusp is deemed to be retracted (and thus a potential risk of repair failure) if less than 19 mm10Schafers H.J. Schmied W. Marom G. Aicher D. Cusp height in aortic valves.J Thorac Cardiovasc Surg. 2013; 146: 269-274Google Scholar (Video 3). A Hegar dilator is used to intubate the aortic root and to measure the size of the annulus. The trainee is reminded to wet the dilator before use and to take care in avoiding tears to the cusps and fenestrations. If introduction of the Hegar dilator is limited by the valve opening, echocardiographic (or gated CT) sizing will help to estimate aortic annulus diameter. From this measurement, the size of the synthetic graft (Valsalva graft; Vascutek Ltd, Glasgow, United Kingdom) and the expansile external annuloplasty ring (Extra-Aortic; Coroneo Inc, Montreal, Quebec, Canada) are chosen (Table 1). If the annulus size lies between 2 groups (ie, between 30 and 31 mm), then the smaller size should be used if there is significant AI in order to further reduce the annulus and increase coaptation (Video 4).Table 1Sizing Chart for the Remodeling Graft (Valsalva) and Calibrated Expansile Annuloplasty Ring (Extra-Aortic Ring), Based on Aortic Annulus Size MeasurementAortic Graft and RingAortic Annulus Diameter (Hegar dilator), mm25-2728-3031-35≥36Valsalva graft, mm26283032Extra-Aortic ring, mm25272931 Open table in a new tab Now the subvalvular sutures for the annuloplasty ring can be placed. Six U sutures are placed circumferentially in the subvalvular plane in a horizontal mattress fashion (Ethicon 3/8 25-mm pledgetted needle; Ethicon LLC, Johnson & Johnson, New Brunswick, NJ). The first suture is placed 2 mm beneath the nadir of the non-coronary cusp, and subsequently beneath the left non-commissure, the left hemi-cusp, the left–right raphe, and the right hemi-cusp (Figure 2). In large annuli (ie, > 28 mm), an extra suture is placed in the muscular part of the annulus in the region of the left–right raphe. These sutures enter inside the aorta and exit the aorta at the lowest limit of the subvalvular dissection plane of the root. The sub-commissural sutures are placed at the same level at the base of the interleaflet triangles. The trainee is taught to always check that the needle has not entered into the sinus, traversing through the base of the cusp. The sixth suture is not placed internally beneath the right non-commissure because doing so may damage the bundle of His and cause heart block. Instead, the sixth suture is placed externally, as a non-pledgetted suture on the left atrium wall at the lowest level of the dissection. These sutures are placed on clips to be used for the annuloplasty ring at a later stage (Video 5). In the case of BAV, we advocate the practice of creating a symmetrical valve and root configuration. To achieve this, the trainee is taught how to accomplish full symmetry of all cusps before the remodeling process. The trainee must align the free edge length of both cusps to correct for any excess free margin. In a BAV, it is common to find the free margin of the fused cusp to have excess length compared with the free margin of the non-fused cusp. A 5-0 polypropylene stay suture is placed through the central nodule of Arantius of the non-fused cusp. This is pulled away from the right non-commissure, while the right non-commissure is pulled in the opposite direction, thereby straightening the free margin. At the same time, the free margin of the fused cusp is grasped carefully and also pulled away from the right non-commissure, thereby straightening it and lining it up adjacent to the non-fused cusp. A second 5-0 polypropylene needle is passed through the free margin of the fused cusp exactly in line with the 5-0 polypropylene suture through the nodule of Arantius of the non-fused cusp. The same steps are repeated on the other side. The 5-0 polypropylene suture through the nodule of Arantius of the non-fused cusp is pulled in the opposite direction now, away from the left non-commissure, while the left non-commissure is pulled the other way. The free margin of the fused cusp is grasped again carefully and pulled away from the left non-commissure, thereby straightening it and lining it up adjacent to the non-fused cusp. The same 5-0 polypropylene needle that had previously been placed through the free margin of the fused cusp is now passed through the free margin, again exactly in line with the 5-0 polypropylene suture through the nodule of Arantius of the non-fused cusp. This has essentially delineated the excess free margin length in the fused cusp and marks the length of plication required to achieve symmetrical free margin lengths in the fused and non-fused cusps. This suture is now tied (knots on the aortic side of the free margin, not on the left ventricular side of the free margin) and the knot is cut short. The 2 commissures are pulled apart to stretch the free margins of both cusps and to ensure that the free margin lengths of both cusps line up and are symmetrical (Figure 3; Video 6). The free margin length of plication required in the fused cusp can often be large. When this is the case, the plication leads to a large area of folded cusp tissue starting at the plication suture on the free margin and extending into the belly of the cusp. If left alone, this folded cusp area will cause billowing during the cardiac cycle. Therefore, we close this folded area using interrupted 5-0 polypropylene sutures. In cases in which the excessive free margin length on the fused cusp is extremely large (> 10 mm), when the free margin is fibrotic, or when the raphe is calcified, a triangular resection of the free margin can be performed. Our standardized approach to BAV root and valve repair is to create a symmetrical valve configuration, meaning that the commissures are placed at 180 degrees to each other. Therefore, the valve-preserving root replacement involves the creation of 2 symmetrical neosinuses using the sinus-shaped Gelweave Valsalva graft (Vascutek Ltd, Glasgow, United Kingdom). A sizing algorithm for the graft is used, based on the diameter of the annulus (Table 1). First, the collar (circumferential crimp) of the graft is excised. This graft has 3 prefabricated lines in its sinus-shaped skirt which divide its circumference at 120-degree intervals. To create 2 neosinuses at 180 degrees, a pen is used to mark the graft at 180 degrees to one of the other lines. These 2 lines now correspond to the commissures in a BAV. The heights of the scallops are cut up to the transition point between the skirt (axial crimp) and body (circumferential crimp) of the Valsalva graft using the 2 marked lines. This ensures the commissures are placed at the same level. The trainee learns to perform remodeling of the root with the use of 5-0 polypropylene sutures. The trainee starts the anastomosis at the position of the right–left raphe and continues until half-way up toward the left non-commissure. Next, the 5-0 polypropylene, which had been placed 1 mm above the left non-commissure, is used to start the running anastomosis from the commissure down. The trainee is taught that the first 3 bites of the running suture that go through the graft must be placed above the neo-sinotubular ridge to avoid distortion of the commissure with the angle of the graft. Subsequent running bites are taken down toward the right–left raphe to meet with the initial 5-0 polypropylene suture. The 2 sutures are tied (Figure 4). The anastomosis is then performed from the right–left raphe half-way up toward the right non-commissure. Subsequently, the suture at the right non-commissure is used to anastomose down and tie to this suture. Thus, each hemi-sinus is anastomosed using 2 converging sutures, which keeps the suture tight and prevents loosening. The trainee learns that if there is a mismatch in size between the graft and the aorta, this technique accommodates for this toward the middle of each hemi-cusp rather than at the nadir or the commissure. Accommodation at the nadir or the commissure would cause valve distortion and subsequent AI. The same steps are performed for the non-coronary sinus (Video 7). The trainee must take his or her time to ensure secure hemostasis by performing a satisfactory anastomosis, so as to avoid bleeding later. It is important for the trainee to understand the significance of cusp eH and its use in measuring the degree of cusp prolapse (one of the most important mechanisms of AI). After root reconstruction with the remodeling technique, the eH of each cusp is measured with a dedicated cusp caliper (Fehling Instruments, Karlstein, Germany). This is performed in accordance to the principles of Schäfers and colleagues.11Schäfers H.J. Bierbach B. Aicher D. A new approach to the assessment of aortic cusp geometry.J Thorac Cardiovasc Surg. 2006; 132: 436-438Google Scholar The 2 commissures are pulled apart to simulate a pressurized root; a 4-0 polypropylene suture is placed at the tip of each commissure and then secured to the drapes under tension. Further sutures are placed at the midpoint of each sinus and retracted to better expose the valve and to allow for placement of the cusp caliper. In BAV, only the eH of the non-fused cusp is measured, to evaluate for residual or induced prolapse. In the fused cusp, the raphe's insertion line into the annulus prevents proper placement of the caliper; this would lead to incorrect measurement and underestimation of the eH. The cusp caliper is set to 9 mm, and its belly is positioned at the nadir or hinge-point of the non-fused cusp (Figure 5). If the eH reaches 9 mm, then no further plication of either cusp is necessary. Of note, placement of the commissures symmetrically at 180 degrees stretches the free edge of the non-fused cusp which de facto resuspends the cusp eH. Care is taken to preserve as much length as possible of the non-fused cusp without plication to preserve maximum opening of the valve for long-term function. However, if the eH does not reach 9 mm, then plicating 5-0 polypropylene sutures are placed in the middle of the free edge of the non-fused cusp, and the cusp is plicated until 9 mm of eH is achieved (Video 8). If a plicating suture is placed in the non-fused cusp, then a subsequent plicating suture will be needed in the fused cusp to maintain the equal free margin length of both cusps. The trainee is taught that a VSRR, such as the remodeling process (or the reimplantation technique), causes a reduction in the intercommissural distance, thereby reducing the STJ. This has the benefit of increasing the coaptation height of the aortic valve. However, there is the detriment of causing a loss of eH of 3 to 4 mm by inducing a symmetrical prolapse. This is the reason why eH is only measured after the root replacement to be able to address any induced prolapse that has occurred. Next is the implantation of the expansile external annuloplasty ring (Extra-Aortic; Coroneo Inc). The selected sized ring is held on its holder while the subvalvular U sutures are passed around it. The sutures are passed around rather than through the ring for the ring to distribute itself around the circumference of the annulus in a symmetrical fashion. The ring is parachuted down, and the sutures are tied while the assistant helps to expose the deeply dissected extent of the root (Figure 6). Because the most fragile section of the root and subvalvular plane lies toward the right–left sinus, these sutures are tied first so not to be under tension. The sutures for the non-coronary sinus are tied last. If too much tension is placed on the sutures when tying, they may tear through the fragile aortic tissue. If this does happen, the aortic tear must be repaired with pericardial pledgetted mattress suture from inside the left ventricular outflow tract (Video 9). The final step is for the coronary buttons to be anastomosed to the Valsalva graft in the appropriate positions. Because of the symmetrical root repair, the left main coronary button should be place slightly closer to the right–left commissure than its original position and rather high to reduce the risk of kinking. The distal anastomosis is completed, air is removed from the heart, and the cross-clamp is released. After release of the cross-clamp, transesophageal echocardiography can immediately be used to assess for any AI, even while still on cardiopulmonary bypass. This is assessed again after weaning from cardiopulmonary bypass to assess the adequacy of the repair. The only acceptable form of residual AI is grade I central AI. Any eccentric AI, however small, is not accepted because it can lead to long-term repair failure. If this is the case, echocardiography is used to assess for the mechanism of residual AI. Subsequently the cross-clamp is reapplied and the graft is transected above the STJ (rather than reopening the distal anastomosis). The valve is reassessed and re-repaired if possible. In the rare case of an unrepairable valve, the external ring is easily cut and removed, and a valve replacement is performed. Because the annulus now enlarges back to its original size, a large prosthetic valve can often be inserted. Different variations and root lesions require specific management or slight alterations to the above-mentioned techniques. The longer the exposure of trainees to these different cases, the more they will gain the experience to manage the multitude of lesion sets encountered in AI. Approximately one-third of cases of BAV will have a right non-fusion morphologic structure. These cases commonly have dilatation of the sinuses of Valsalva and will therefore require VSRR. Apart from the different location of the right coronary button, there are a small number of other considerations to keep in mind. Often the dissection plane between the