Surgical Anatomy of the Aortic Annulus: Landmarks for External Annuloplasty in Aortic Valve Repair Nizar Khelil, MD, Ghassan Sleilaty, MD, Michele Palladino,

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Surgical Anatomy of the Aortic Annulus: Landmarks for External Annuloplasty in Aortic Valve Repair Nizar Khelil, MD, Ghassan Sleilaty, MD, Michele Palladino, MD, Mahmoud Fouda, MD, Remi Escande, MD, Mathieu Debauchez, MD, Isabelle Di Centa, MD, Emmanuel Lansac, MD, PhD The Annals of Thoracic Surgery Volume 99, Issue 4, Pages 1220-1226 (April 2015) DOI: 10.1016/j.athoracsur.2014.12.034 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Transillumination of the aortic root after dissection of the subvalvular plane with view from the (A) noncoronary (NC) sinus and from the (B) right cusp (RC)–left cusp (LC) commissure. (C) Open ring (Extra-Aortic Open Ring, CORONEO, Inc, Montreal, QC, Canada) for isolated aortic valve repair with subvalvular annuloplasty without coronary detachment. (D) Remodeling root reconstruction associated to expansible (25-mm diameter × 3-mm cross-section) aortic annuloplasty ring (Extra-Aortic Low Profile, CORONEO, Inc) for root aneurysm repair with a Gelweave Valsalva tube (Vascutek/Terumo, Renfrewshire, United Kingdom). The Annals of Thoracic Surgery 2015 99, 1220-1226DOI: (10.1016/j.athoracsur.2014.12.034) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) The aortic root has been opened at the commissural level in between the right and left coronary sinuses and spread apart, and the cusps were removed. The blue line indicates the sinotubular junction (STJ), and the green line indicates the aortic annulus (AA). The scale drawing shows the subvalvular dissection plane line and the schematic 3-dimensional aortic annular view from the (B) right (R) cusp, (C) noncoronary (NC) cusp, and (D) left (L) cusp. The Annals of Thoracic Surgery 2015 99, 1220-1226DOI: (10.1016/j.athoracsur.2014.12.034) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Heights of dissection at the level of the aortic annulus: nadir of (A) left cusp (LC), (B) right cusp (RC), and (C) noncoronary (NC) cusp; and at the base of the (D) NC–LC interleaflet triangle, (E) LC–RC interleaflet triangle, and (F) RC–NC interleaflet triangle. The Annals of Thoracic Surgery 2015 99, 1220-1226DOI: (10.1016/j.athoracsur.2014.12.034) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Thickness of tissue at the level of the aortic annulus: nadir of the (A) of left cusp (LC), (B) right cusp (RC), and (C) noncoronary (NC) cusp, and at the base of the (D) NC–LC interleaflet triangle, (E) the LC–RC interleaflet triangle, and (F) the RC–NC interleaflet triangle. The Annals of Thoracic Surgery 2015 99, 1220-1226DOI: (10.1016/j.athoracsur.2014.12.034) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions