Stable partial dehiscence of aortic homograft inserted freehand by using the subcoronary intra-aortic root noncoronary sinus Ross scallop inclusion technique

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Stable partial dehiscence of aortic homograft inserted freehand by using the subcoronary intra-aortic root noncoronary sinus Ross scallop inclusion technique Richard Hopkins, MD, Howard Gitter, MD, Jeffrey Stave, DO, Arthur Bert, MD, Michael Atalay, MD The Journal of Thoracic and Cardiovascular Surgery Volume 135, Issue 1, Pages 214-216.e1 (January 2008) DOI: 10.1016/j.jtcvs.2007.04.076 Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 (a) Transverse axis magnetic resonance image through the aortic root demonstrates the dehiscence flap (short arrows) adjacent to the aortic valve (arrowheads). (b) The image is during midsystole. The blind-ending pouch created by the dehiscence increases in size during systole, slightly compressing the noncoronary sinus. PA, Pulmonary artery; LA, left atrium; LM, left main coronary artery; RCA, right coronary artery; RA, right atrium. The Journal of Thoracic and Cardiovascular Surgery 2008 135, 214-216.e1DOI: (10.1016/j.jtcvs.2007.04.076) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 The subcoronary inclusion “scallop” technique in which more of the homograft noncoronary sinus is retained, putatively for better pillar alignment and “reinforcement” of the aortotomy. A, The aortic allograft is trimmed with extensive removal of sinus tissue, except for the noncoronary sinus, in which a shallow scallop is created to fit below the native (recipient) aortotomy. B, After the circumferential proximal suture line is completed, the distal suture line is constructed with 3 polypropylene sutures, beginning at the bottom of each sinus and finishing at the top of each commisural pillar. The knot is placed outside the aorta to reduce thromboembolic risk. C, It is at the top of the “scalloped” sinus where the suture line has pulled through, allowing fluttering and thereby creating the blind pouch. Native aorta outside the allograft is not deformed. The Journal of Thoracic and Cardiovascular Surgery 2008 135, 214-216.e1DOI: (10.1016/j.jtcvs.2007.04.076) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions

Figure E1 Long-axis companion images to Figure 1. (a) The long arrow indicates the entry site into the pouch. (b) Note increase in pouch size during systole. PA, Pulmonary artery; RA, right atrium; Ao, aorta. The Journal of Thoracic and Cardiovascular Surgery 2008 135, 214-216.e1DOI: (10.1016/j.jtcvs.2007.04.076) Copyright © 2008 The American Association for Thoracic Surgery Terms and Conditions