Aortic root enlargement: What are the operative risks? Jayesh Dhareshwar, MD, Thoralf M. Sundt, MD, Joseph A. Dearani, MD, Hartzell V. Schaff, MD, David J. Cook, MD, Thomas A. Orszulak, MD  The Journal of Thoracic and Cardiovascular Surgery  Volume 134, Issue 4, Pages 916-924 (October 2007) DOI: 10.1016/j.jtcvs.2007.01.097 Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Original figures from articles published by Nicks and colleagues (A) and Manouguian and Seybold-Epting (B) first describing posterior root enlargement techniques. Figure 1A is reprinted from Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement. Thorax. 1970;25:339-46. Reproduced with permission from the BMJ Publishing Group. Figure 1B is reprinted from Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg. 1979;78:402-12. Reproduced with permission from Mosby. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 916-924DOI: (10.1016/j.jtcvs.2007.01.097) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 A: a, Nicks’ aortic root enlargement is accomplished by extending the aortotomy incision across the aortic annulus into the anterior leaflet of the mitral valve. b, Care must be taken to carry this incision posteriorly into the center of the anterior leaflet. c, The defect is closed with autologous or bovine pericardium. Figure 2B: d, Valve prosthesis is sutured in a supra-annular position. In the region of the patch, the sutures are passed full thickness from outside the patch to inside. e, The pericardial patch is then used to facilitate closure of the aortotomy. The Journal of Thoracic and Cardiovascular Surgery 2007 134, 916-924DOI: (10.1016/j.jtcvs.2007.01.097) Copyright © 2007 The American Association for Thoracic Surgery Terms and Conditions