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

2019; Elsevier BV; Volume: 107; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2019.03.013

1552-6259

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

Aortic aneurysm repair treatments

Dr Lansac discloses a financial relationship with CORONEO Inc.The Video 1, Video 2, Video 3, Video 4, Video 5, Video 6, Video 7, Video 8, Video 9, Video 10, Video 11, Video 12, Video 13 can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.03.013] on http://www.annalsthoracicsurgery.org.In recent years, a great deal of attention has been paid to the different techniques of aortic valve preservation in aortic root surgery. To avoid long-term disadvantages of anticoagulation, thromboembolism, endocarditis, and valve degeneration, valve-sparing root replacement (VSRR) procedures, which were initially introduced in the early 1990s, have shown larger uptake. Dr Lansac discloses a financial relationship with CORONEO Inc. The Video 1, Video 2, Video 3, Video 4, Video 5, Video 6, Video 7, Video 8, Video 9, Video 10, Video 11, Video 12, Video 13 can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.03.013] on http://www.annalsthoracicsurgery.org. Recent international guidelines mention "aortic annuloplasty" as part of a class I indication involving "aortic valve repair, using the reimplantation techniques or the remodeling technique with aortic annuloplasty, is recommended in young patients with aortic root dilation and tricuspid aortic valves" [1Erbel R. Aboyans V. Boileau C. et al.2014 ESC Guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC).Eur Heart J. 2014; 35: 2873-2926Crossref PubMed Scopus (2767) Google Scholar]. However, the rate of valve repair remains low except in a few expert centers, which may be partly due to fear of repair failure. Failure and recurrence of aortic insufficiency can be multifactorial, involving elements such as an untreated dilated annulus (>25 to 28 mm) and residual cusp prolapse (whether unrecognized or an induced prolapse after root reconstruction). To address these issues, we have developed a standardized aortic valve repair approach that addresses the annulus, the aorta, and the valve itself. This involves a physiological reconstruction of the aortic root according to the remodeling technique, cusp effective height resuspension, and a subvalvular external aortic ring annuloplasty. The remodeling technique described by Yacoub [2Sarsam M.A. Yacoub M. Remodeling of the aortic valve anulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438Abstract Full Text PDF PubMed Google Scholar] involves replacing the diseased sinuses of Valsalva with 3 tongue-shaped extensions of a vascular graft, thus maintaining the sinus shape of the root as well as the aortic valve leaflets, their hinges, interleaflet triangles, and commissures. It provides physiological cusp movement within the 3 reconstructed neosinuses and preserves root expansibility through the interleaflet triangles. We combine this with a subvalvular expansible external ring annuloplasty (to reduce the annulus, thereby increasing cusp coaptation height and restoring the ratio between the sinotubular junction and the annulus) as well as leaflet repair and resuspension of the cusp effective height. Our group has performed more than 600 procedures of this kind, with 7-year freedom from valve-related reoperation, aortic insufficiency grade 3 or higher, and major adverse valve-related events of 99.1%, 100%, and 96.3%, respectively [3Lansac E. Di Centa I. Sleilaty G. et al.Remodeling root repair with an external aortic ring annuloplasty.J Thorac Cardiovasc Surg. 2017; 153: 1033-1042Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar]. We have worked over the years to develop a standardized technique for aortic root repair that is evidence-based and reproducible. This involves a systematic approach and step-wise progression of the operation to allow the surgeon to safely and competently perform the root replacement as well as assess and embark on the correct strategy for valve repair. We have taught these techniques at an international level, and several fellows have learned and performed these operations using these standardized techniques. Here we embark on a series of deep-dives into the teaching of our standardized techniques of aortic root and valve repair, including root replacement in tricuspid and bicuspid aortic valves as well as isolated repair of tricuspid and bicuspid valves. In this first article of four in the series (Fig 1), we describe our approach to teaching valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty in tricuspid aortic valves. We describe teaching of the standardized technique for straightforward cases as well as for specific valve lesion sets. At the heart of learning advanced techniques of aortic root repair is exposure to a large volume of cases. This inevitably involves training in a high-volume center for aortic surgery that has a large case mix of aortic insufficiency, dystrophic aortic aneurysms, and connective tissue disorders. The trainee or fellow must already have received adequate experience in operative surgery, have a sound knowledge of aortic pathophysiology and root anatomy, and have performed a number of composite aortic root replacements. We recommend attendance at one of the many international courses in root surgery, with use of wet laboratories and live-on-tape videos of the different procedures. Furthermore, during all of our operative procedures, we record high-definition video of the procedure with a mounted mobile camera that is very close to the operative field. This not only adds to our large video library of recorded cases, which is a resource for teaching our trainees, but is also a valuable way for trainees to learn how to improve by watching themselves doing the operation. An important aspect of learning the techniques of root and valve repair is to learn the assessment and decision-making process. Imaging assessment of the aortic root and valve in the form of echocardiography (Video 1) and gated computed tomography is very important, and we want the trainee to use the results of these imaging modalities to propose a preliminary operative plan for the patient with regards to intervention on the annulus, sinuses of Valsalva, leaflets, and sinotubular junction and ascending aorta (Fig 1). We have devised a standardized order of steps that is adhered to in every case and provides a framework for progressing through the operation:1.Excision of sinuses and dissection down to subvalvular plane2.Valve assessment•Inspection•Geometric height measurement•Annulus diameter measurement•Commissural assessment: fenestrations and angle3.Sizing of aortic graft and external annuloplasty ring4.Subvalvular U sutures5.Alignment of cusp free edges6.Root remodeling7.Effective height measurement and cusp resuspension8.Subvalvular ring implantation9.Coronary reimplantation10.Distal aortic anastomosis Trainees are expected initially to know all the steps of the procedure and demonstrate this while assisting the surgeon before embarking on performing the procedures themselves. The patient is positioned supine with a sandbag under the shoulders to improve exposure to the aortic root and ascending aorta. A limited skin incision is made with a median sternotomy or a ministernotomy, followed by systemic heparinization. To establish cardiopulmonary bypass, arterial cannulation of the aortic arch and venous cannulation of the right atrium is performed with a flat two-stage cannula or percutaneous femoral vein cannulation used in cases of ministernotomy. The ascending aorta is clamped as distally as possible. A right superior pulmonary vein vent is inserted. Given that most of these patients will have a degree of aortic insufficiency (AI), direct antegrade ostial cardioplegia is required. The aorta is transected fully 2 cm proximal to the cross-clamp (to prepare for distal aortic anastomosis later), and the proximal aorta is incised vertically down to the sinotubular junction. Direct cardioplegia is given into the coronary ostia using Custodiol HTK cardioplegia solution (Essential Pharmaceuticals, LLC, Durham, NC) for 7 minutes. After a gross inspection of the valve to identify any obvious contraindications for repair (multiple ruptured fenestrations, extensive calcification, or retraction), the trainee first learns to perform the deep root dissection down to the subvalvular plane. Although this deep dissection can lead to damage to surrounding structures if not done with care, it is important for the trainee to embark on this as early as possible to gain as much experience of this dissection during his or her period of training. This dissection is performed using cautery at the same setting as used for internal mammary harvest, although it can also be performed using scissors. The aim is to reach below the level of the annulus, which corresponds to below the nadir of the 3 cusps. The dissection is usually performed in the following order: non-coronary sinus, then left sinus, then right sinus. The plane between the aortic wall and the roof of the left atrium is dissected until it is freed to a level that is below the nadir of the non-coronary cusp. The non-coronary sinus is excised, leaving a 3-mm rim of aortic tissue from the hinge point of the non-coronary cusp and 3 to 5 mm above each commissure. A 5-0 polypropylene suture is placed 1 mm above each commissure and placed on a protected clip, because it will help exposure and will be used later for suturing the remodeling graft. Next, the trainee performs dissection in the plane between the left coronary sinus and the pulmonary artery. The aortopulmonary ligament is encountered here and can be of varying thickness in different individuals. It must be divided to reach the subvalvular plane. The left sinus is excised, leaving a 3-mm rim of aortic tissue, and the left coronary button is prepared with minimal mobilization to avoid kinking. Further dissection is performed down to the subvalvular plane using cautery. The trainee is taught to dissect in a tangential manner between the left sinus and the pulmonary artery to avoid entering the left ventricular outflow tract. Finally, the right coronary sinus is excised, and the right coronary button is prepared. The trainees often find this plane between the right sinus and the right ventricular outflow tract/infundibulum to be the most challenging. It must be performed with care, and the plane of dissection must stay very close to the aortic wall to avoid entering the right ventricle. If there is any doubt about an injury to the right ventricle or right atrium, the venous line is clamped and the heart is allowed to fill in order to show bleeding from these injuries. It is important to recognize this early because repair at this stage is much easier. The limit of the dissection plane is always at the interface between the right-non commissure and the membranous septum because dissecting to the subvalvular plane in this location is not possible. It is important to avoid burn injury to the bundle of His; therefore, dissection here is performed with scissors. For all 3 sinuses, the aorta is excised, leaving a 3-mm rim of aortic tissue from the hinge point of the cusp and 3 to 5 mm above each commissure. A 5-0 polypropylene suture is placed 1 mm above each commissure and placed on a protected clip, because it will be used later for suturing the remodeling graft (Video 2). Counterintuitively, we reserve full valve assessment until after the sinuses have been excised. This is because the cusps and commissures are more easily maneuvered, visualized, and assessed after sinus excision. It is important to allow the trainees to make their own assessment before the surgeon advises them of their findings. The leaflets are inspected for tissue quality and leaflet mobility. Fenestrations are assessed to establish those that are small and physiologically satisfactory to leave and those that are large and ruptured and requiring repair. Areas of calcification are examined. At this point, geometric height is measured—the nodule of Arantius is grasped carefully with forceps and the leaflet is stretched gently to use a ruler to measure from the nadir of the cusp to the free edge. In tricuspid aortic valves, the cusp is deemed to be retracted (and thus a potential risk for repair failure) if less than 16 mm (Video 3). The annulus size is then measured using a Hegar dilator, and this measurement is used to choose the size of the synthetic graft and the expansile external annuloplasty ring (Extra-Aortic; CORONEO Inc, Montreal, QC, Canada; Table 1). The trainee is taught that if the annulus size lies between two sizes (ie, between 27 and 28 mm), then the smaller size should be used if there is significant aortic insufficiency 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 RingaCORONEO Inc, Montreal, QC, Canada.) Based on Aortic Annulus Size MeasurementVariableAortic Annulus Diameter (Hegar dilator, mm)25–2728–3031–35≥36Valsalva graft, mm26283032Extra-Aortic ring, mm25272931a CORONEO Inc, Montreal, QC, Canada. Open table in a new tab The next step for the trainee to learn is placement of the subvalvular sutures for the annuloplasty ring. Six U sutures are placed circumferentially in the subvalvular plane in a horizontal mattress fashion (Ethicon 3/8 25-mm needle; Ethicon, Somerville, NJ). One U suture is placed beneath the nadir of each cusp and one beneath each commissure (Fig 2). When the annulus is very large (ie, >28 mm), an extra suture can be placed in the muscular part of the annulus underneath the right-left commissural area. The trainee is taught to place these as pledgetted mattress sutures entering 2 mm beneath the nadir of each cusp inside the aorta and exiting the aorta at the lowest limit of the subvalvular dissection plane of the root. The subcommissural sutures are placed at the same level at the base of the interleaflet triangles. It is important for the trainee to check that the needle has not traversed through the base of the cusp, into the sinus, and out of the aortic wall, particularly at the right coronary cusp. To avoid heart block, we want to avoid placing a U suture through the membranous septum and the nearby bundle of His. Therefore the sixth suture is not placed at the subvalvular level beneath the right-non commissure, but is instead placed externally. It is placed 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). Before the remodeling process is performed, full symmetry of all cusps must be established. To do this, the trainee must align the free edge length of all 3 cusps. This ensures correction of any excess free margin before the remodeling process. For this step, a 5-0 polypropylene stay suture is placed through the central nodule of Arantius of each cusp. Subsequently, each hemicusp is compared to its neighbor in a systematic way. The left-right commissure is pulled away while the central 5-0 polypropylene sutures of the left and right cusps are pulled in the opposite direction—this demonstrates any excess length of one of the hemicusps. The right-non commissure is then pulled away while the central 5-0 stay sutures of the right and non-coronary cusps are pulled in the opposite direction, assessing for any excess length. Finally, similar assessment is made with the left-non commissure and the left and non-coronary cusps. It is important for the trainee to show delicate handling of the stay sutures because any excess tension can cause leaflet tears. If excess length is seen, a plication 5-0 or 6-0 polypropylene is inserted into the free margin of the elongated cusp, and the free edge length is reduced by plication (Fig 3, Video 6). We perform remodeling of the aortic root using the sinus-shaped Gelweave Valsalva graft (Vascutek Ltd, Glasgow, United Kingdom). The size of the graft is chosen according to the sizing algorithm of the annulus (Table 1). This graft has 3 existing lines in its sinus-shaped skirt that divide its circumference at 120-degree intervals— these lines correspond to the commissures in a tricuspid aortic valve. First, the collar (circumferential crimp) of the graft is excised, and 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 3 existing lines. This ensures the commissures are placed at the same level. Reconstruction and remodeling of the root is undertaken using 5-0 polypropylene. The trainees are reminded to take their time to ensure secure hemostasis during this step, because bleeding later can take more time and effort to deal with. The anastomosis is started at the nadir of the left coronary sinus and continued until half-way up toward the left-non commissure. Subsequently, the 5-0 polypropylene that had been placed 1 mm above the left-non commissure is used to anastomose from the commissure down. Usually, 3 continuous bites are taken through the graft above the neosinotubular ridge to avoid distortion of the commissure with the angle of the graft, and then subsequent running bites are taken down toward the nadir to meet with the initial 5-0 polypropylene suture. The 2 sutures are tied (Fig 4). The anastomosis is then performed from the nadir of the left sinus half-way up toward the right-left commissure. Subsequently, the suture at the right-left commissure is used to anastomose down and tie to this suture. By anastomosing each hemisinus using 2 converging sutures, this keeps the anastomosis suture tight and prevents loosening of the running suture. Furthermore, if there is a mismatch in size between the graft and the aorta, it is better to accommodate for this toward the middle of each hemicusp rather than at the nadir or the commissure, because these would cause valve distortion and regurgitation. The same steps are performed for the right and non-coronary sinuses (Video 7). After root reconstruction with the remodeling technique, the trainee measures the effective height of each cusp using a dedicated cusp caliper (Fehling Instruments, Karlstein, Germany) according to the principles of Schäfers and colleagues [4Schäfers H.J. Bierbach B. Aicher D. A new approach to the assessment of aortic cusp geometry.J Thorac Cardiovasc Surg. 2006; 132: 436-438Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar]. To perform these measurements accurately, the 3 commissures must be pulled apart as much as possible to simulate a pressurized root— this is performed by placing a 4-0 polypropylene suture at the tip of each commissure and securing these under tension to the drapes. All 3 cusps are assessed in turn to evaluate for residual or induced prolapse. The trainee is taught to set the cusp caliper to 9 mm and position its belly at the nadir or hinge point of each cusp (Fig 5). If the effective height does not reach 9 mm, plicating 5-0 polypropylene sutures are placed in the middle of the free edge, and the cusp is plicated until a 9 mm effective height is achieved (Video 8). The expansile external annuloplasty ring (Extra-Aortic; CORONEO Inc, Montreal, QC, Canada) is now implanted. The subvalvular U sutures are passed around the expansile annuloplasty ring. By passing the sutures around rather than through the ring, the ring is able to distribute itself along the circumference of the annulus and be symmetrical. The ring is parachuted down, and the sutures are tied (Fig 6). The trainee is reminded to ensure not too much tension is placed on the sutures to avoid the pledgetted sutures tearing through the fragile aortic tissue. In case of tearing, careful closure with pericardial pledgetted mattress sutures from inside the left ventricular outflow tract should be performed and a new anchoring pledgetted suture placed for the ring (Video 9). After the subvalvular ring is implanted, the coronary buttons are anastomosed to the Valsalva graft in the appropriate positions, ensuring they have no rotation, kinking, or tension. It is important to not be too close to the commissure to avoid inadvertently taking bites of the leaflets/commissures. The distal anastomosis is completed, followed by de-airing and release of the cross-clamp. The patient is weaned from cardiopulmonary bypass, and transesophageal echo is used to assess adequacy of the repair. We aim for no residual AI; however, grade I AI is accepted if it is central. If there is any eccentric jet of AI, however small, this is not accepted because it will eventually lead to long-term repair failure. In these cases, the cross-clamp is reapplied, the graft is transected above the sinotubular junction (rather than reopening the distal anastomosis), and the valve is reassessed and rerepaired. A number of different cusp lesions may be encountered that require attention. Learning how to manage these lesions often requires exposure to a large volume of cases in order for the trainee to see the different variations and how to repair them. It is important for the trainee to see a number of different leaflet fenestrations to learn which ones are physiological (and thus should be left alone) and which ones are pathological (and require repair). Fenestrations run along the cusp free edge originating from the commissure towards the middle of the free margin. When excessively large, or even ruptured, they require repair with a decellularized heterologous patch (for example, CardioCel; Admedus, Toowong, QLD, Australia) or glutaraldehyde-treated autologous pericardium. The patch should be thin and long (often needing to reach from the commissure to the nodule of Arantius), with one side as a straight edge (to recreate the cusp free margin) and one side curved (to be anastomosed to the cusp). A 6-0 polypropylene running suture is used to anastomose the patch to the cusp, starting from the apex of the patch closest to the nodule of Arantius and continuing towards the commissure. A second running suture should run along the straight free edge of the patch to strengthen it (Fig 7, Video 10). Full assessment of each commissure is vital, because one mechanism of AI that can be missed is that of a splaying apart of the commissure. This separates the 2 adjacent cusp free margins and may even generate different cusp heights. It can often be seen in combination with ruptured fenestrations. Commissural diastasis should be repaired by a figure-of-8 suture using 5-0 polypropylene (Video 11). It is not uncommon for cusps to have areas of calcification. These may cause some restriction of cusp mobility and affect the geometric height. With experience comes judgment about which valves can be decalcified, which needs to be done with care and caution. Stripping of small areas of calcification from the cusps can be achieved using forceps, curettes, and even sharp dissection with a scalpel (Video 12). There are some instances in which a bicuspid aortic valve is encountered in its minor form, where the height of the raphe is only slightly lower than the height of the other 2 commissures, and the raphe and 2 commissures are placed at nearly 120 degrees from each other. Fenestrations are commonly present at the raphe. These valves should be managed just like a tricuspid root. When the root is dilated, the remodeling process should be undertaken just as though the valve was tricuspid, with 3 equally sized scallops spaced at 120 degrees from each other. The raphe should be treated like a commissure and sutured to the Valsalva graft at the same height as the other commissures (Video 13). The current rate of valve-sparing aortic root surgery and aortic valve repair remains low and is practiced on highly selected patients, except in experienced centers of excellence. Despite 80% of aortic root aneurysm operations being performed for dystrophic AI, only 14% of these patients receive a valve-sparing root operation according to The Society of Thoracic Surgeons database [5Stamou S.C. Williams M.L. Gunn T.M. Hagberg R.C. Lobdell K.W. Kouchoukos N.T. Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database.J Thorac Cardiovasc Surg. 2015; 149: 116-122Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar]. This statistic questions the reproducibility of VSRR procedures. We strongly believe this is down to the lack of standardization of technique. To address this, we have developed a standardized approach to the aortic root and valve, including physiological reconstruction of the root using the remodeling technique, subvalvular external aortic ring annuloplasty, and cusp repair using cusp effective height resuspension. Long-term outcomes after mechanical composite valve and graft replacements (Bentall procedure) in a meta-analysis of 7,629 patients have shown a pooled early mortality of 6% and an annual late mortality of 2.0% per year, equating to a 10-year survival of 80% [6Mookhoek A. Korteland N.M. Arabkhani B. et al.Bentall procedure: a systematic review and meta-analysis.Ann Thorac Surg. 2016; 101: 1684-1689Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar]. These outcomes are worse than would have been expected for a mechanical valve. Short-term and long-term survival were both shown to be better for VSRR in a meta-analysis of 4,777 patients, showing an early mortality of 2% and late mortality of 1.5% per year (10-year survival of 85%) [7Arabkhani B. Mookhoek A. Di Centa I. et al.Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: a systematic review and meta-analysis.Ann Thorac Surg. 2015; 100: 1126-1131Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar]. They show the need to reassess the indications and use of prosthetic valves in root surgery. The Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysms of the Aortic Root (CAVIAAR) trial demonstrated the safety of VSRR, using the remodeling technique and subvalvular annuloplasty, by showing similar 30-day mortality compared with a mechanical Bentall procedure [8Lansac E. Bouchot O. Arnaud Crozat E R. et al.Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study.J Thorac Cardiovasc Surg. 2015; 149: S37-S45Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar]. There was a trend toward more major adverse events in the Bentall group (odds ratio, 2.52; p = 0.09). At 4 years of follow-up, crude and propensity-matched analysis confirmed that freedom from valve-related death and freedom from hemorrhagic events were both significantly better after valve repair than after replacement (99.1% vs 94.3% [p < 0.001] and 89.2% vs 78.3% [p = 0.02], respectively), whereas freedom from valve-related reoperation was similar (p = 0.223). Long-term outcomes have even further improved as a result of further development of aortic valve repair techniques, such as improved repair stabilization using a calibrated expansile annuloplasty ring as well as cusp effective height assessment. In a cohort of 177 patients, we demonstrated a 7-year freedom from valve-related reoperation, aortic insufficiency grade 3 or higher, and major adverse valve-related events of 99.1%, 100%, and 96.3%, respectively, with similar results for bicuspid and tricuspid valve repair [3Lansac E. Di Centa I. Sleilaty G. et al.Remodeling root repair with an external aortic ring annuloplasty.J Thorac Cardiovasc Surg. 2017; 153: 1033-1042Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar]. Sparing of the aortic valve while replacing the root and downsizing a dilated annulus can be performed by both the reimplantation technique as well as by remodeling with annuloplasty. Our choice to use remodeling plus annuloplasty is based on a number of factors related to standardization of technique. The remodeling root reconstruction we describe here places the commissures at 120 degrees (or 180 degrees for a bicuspid valve) at the same height. The external ring annuloplasty is performed at the end of the procedure, as opposed to the reimplantation technique where the annuloplasty is performed at the beginning with the proximal suture line. This means valve assessment and effective height measurement is made more difficult because the valve is constrained by the graft, whereas with our technique, the effective height caliper can be used in an unconstrained annulus. Perhaps more pertinent to the teaching process and the learning curve for new surgeons, the fall-back option if the valve repair is not satisfactory is to rearrest the heart and replace the aortic valve within the root reconstruction. In the remodeling plus annuloplasty technique, the annuloplasty ring can simply be cut, leaving a large annulus to implant a large prosthetic valve. In the reimplantation technique, however, the annuloplasty cannot be easily reversed, thereby only leaving space for a small valve. To ensure appropriate uptake of valve-sparing root procedures, safe conduct of the operation, and excellent long-term outcomes, it is imperative that surgeons are taught these procedures in a systematic way with standardized steps that are evidence-based and reproducible. Pouya Youssefi receives funding from the Society for Cardiothoracic Surgery in Great Britain & Ireland (SCTS) Ethicon Fellowship, Royal College of Surgeons of England Research Fellowship, and Dunhill Medical Trust Research Fellowship. Emmanuel Lansac has consultant agreements with CORONEO Inc (www.coroneo.com), in connection with the development of an aortic ring bearing the trade name "Extra-Aortic." eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmNmZlOTNmNGJhNjA3MWVlNzMzZDE1M2I0ODkwNmUwNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc5NTA2NzI1fQ.N8PCWPufRSi87WJY9WNebC9uhZ-GPqWlC5l9Hk3_2uE3MwO8J76rX1zYvnbMyRBZ6U_sN373xCPwe9yja460_ix-8VufGflsaj1vizq-dI6xoqdcYDck6SzJUqlr0UpoPACN80Kp2ob4uBKyfMWiFXpLwUIFJ_dQBHwsuluYC8Gi0QdxkqyujwfxnWXb50w7najsUtQ0ysaAkPQ_U8s8Y2tI_4lJy5B96dnPPmZehXOKb9KGSDQFMBrBM3VQHjwpsx9z5YLXuno1r6w4r5cnXozJjKWlsbRTNSW25wmpsoyiO7-P4F3QMBxeWtWKjfPvL8uuA4fpaoTY7UivVvnYGg Download .mp4 (25.94 MB) Help with .mp4 files Video 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