Replacement of a Stented Biologic Prosthesis Within an Aortic Valved Conduit Giuseppe Gatti, MD, Alessandro Moncada, MD, Alessandro Minati, MD, Aniello.

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Replacement of a Stented Biologic Prosthesis Within an Aortic Valved Conduit Giuseppe Gatti, MD, Alessandro Moncada, MD, Alessandro Minati, MD, Aniello Pappalardo, MD The Annals of Thoracic Surgery Volume 93, Issue 3, Pages e53-e55 (March 2012) DOI: 10.1016/j.athoracsur.2011.10.045 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) Step in preparing the composite valved conduit that was used in the primary operation (the original technique) in the case described in the report. A vascular graft 5 mm larger than the labeled valve size is selected and everted at one extremity for approximately 3 cm. The stented bioprosthesis is then placed inside the tube graft and secured to the doubled end of the tube with a continuous polypropylene suture. The everted segment is then pulled down below the valve and beveled as a miniskirt. (B) The polypropylene suture cannot be seen by looking at the upper side of the valve. The Annals of Thoracic Surgery 2012 93, e53-e55DOI: (10.1016/j.athoracsur.2011.10.045) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 (A) Subcoronary implantation of the new biologic valve into the graft. The sewing ring of the valve was fixed with multiple interrupted mattress sutures to the graft, exactly along the prominent suture line (arrow) of the excised bioprosthesis (prosthetic vascular fold). (B) The new biologic valve within the graft. The Annals of Thoracic Surgery 2012 93, e53-e55DOI: (10.1016/j.athoracsur.2011.10.045) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) The improved technique. (B) The polypropylene suture can be seen by looking at the upper side of the valve. The Annals of Thoracic Surgery 2012 93, e53-e55DOI: (10.1016/j.athoracsur.2011.10.045) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions