Isolated Bicuspid Aortic Valve Repair With Double Annuloplasty: How I Teach It

Abstract

Dr Lansac discloses a financial relationship with Coroneo, Inc.The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.09.016] on http://www.annalsthoracicsurgery.org.Following on from the success of mitral valve repair, aortic valve (AV) repair is now recognized as a recommended treatment for selected patients with aortic insufficiency (AI) or proximal aorta aneurysm. In recent years, the main schools of aortic valve (AV) repair have standardized the approaches and techniques to enhance the reproducibility of AV repair. International guidelines now recommend a “heart team discussion” for selected patients with “pliable, non-calcified tricuspid or bicuspid” AI “in whom aortic valve repair may be a feasible alternative to valve replacement” (Class I C indication).1Falk V. Baumgartner H. Bax J.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2017; 52: 616-664Crossref PubMed Scopus (9) Google Scholar Dr Lansac discloses a financial relationship with Coroneo, Inc. The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.09.016] on http://www.annalsthoracicsurgery.org. We have developed a standardized technique for aortic valve repair that is reproducible, and consists of a systematic approach to allow the surgeon to safely and competently embark on the correct strategy for valve repair. We have taught these techniques at our international courses, with many surgeons having learned to perform these operations using these standardized steps. The technique addresses the valve cusps as well as the annulus and sinotubular junction (STJ).2Youssefi P. El-Hamamsy I. Lansac E. Rationale for aortic annuloplasty to standardise aortic valve repair.Ann Cardiothorac Surg. 2019; 8: 322-330Crossref PubMed Scopus (21) Google Scholar The physiologic ratio of STJ/annulus is 1.2,3Lansac E. Di Centa I. Dynamic anatomy to aortic annuloplasty: the tale of the ring.in: Yankah C. Weng Y. Hetzer R. Aortic Root Surgery: The Biological Solution. Springer-Verlag, Berlin Heidelberg2010: 102-132Google Scholar and we restore root geometry back to this ratio using a double subvalvular and supravalvular annuloplasty. We also perform systematic effective height assessment and resuspension. This is the fourth and final article of the series, which are deep dives into how we teach the standardized techniques of aortic root and valve repair, including root replacement in tricuspid aortic valves (TAV) and bicuspid aortic valves (BAV), as well as isolated repair of TAV and BAV (Figure 1). Previously, we have described root remodeling and annuloplasty in both TAV and BAV, as well as isolated AV repair in TAV.4Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Isolated tricuspid aortic valve repair with double annuloplasty: how I teach it.Ann Thorac Surg. 2019; 108: 987-994Abstract Full Text Full Text PDF Scopus (6) Google Scholar In this fourth article, we describe our approach to teaching isolated AV repair using double subvalvular and supravalvular annuloplasty in BAV. At the very beginning of their fellowship, trainees are taught a structural approach to the management of AI, which allows for planning of the surgical technique to be adopted depending on the size of the aortic root (Figure 1). An isolated AV repair can only be performed if both the sinuses of Valsalva and ascending aorta are less than 45 mm (otherwise a valve-sparing root replacement with subvalvular annuloplasty, or a tubular aorta replacement with subvalvular annuloplasty will need to be performed).4Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Isolated tricuspid aortic valve repair with double annuloplasty: how I teach it.Ann Thorac Surg. 2019; 108: 987-994Abstract Full Text Full Text PDF Scopus (6) Google Scholar It is important for the trainee to appreciate the importance of addressing the three different geometric components of the aortic root when embarking on AV repair: the annulus, the STJ, and the valve cusps. Central to addressing the annulus and the STJ is the restoration of the normal physiologic STJ/annulus ratio of 1.2. In almost all cases of dystrophic AI (which makes up the majority of cases of AI in the western world7Iung B. Baron G. Butchart E.G. et al.A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease.Eur Heart J. 2003; 24: 1231-1243Crossref PubMed Scopus (2633) Google Scholar), the annulus is dilated more than 25 mm (and the STJ is commonly dilated more than 30 mm). By reducing the annulus and the STJ (in the form of a double subvalvular and supravalvular annuloplasty), and restoring their physiologic ratio, the competence of the aortic valve is improved by increasing the cusps’ coaptation area, much like an annuloplasty does in mitral valve repair. The trainee learns with time that BAVs can exist in a variety of configurations. Not only is the fusion pattern of the valve important (right-left fusion or right-non fusion), but also pertinent to the repair strategy is the commissural angle between the two true commissures. The commissural angle in a BAV can range anywhere between 120 degrees (very asymmetrical valve, as in the case of a minor form of BAV where the raphe is often very short corresponding to a “tricuspid-like configuration”) to 180 degrees (the very symmetric and rare true type 0 BAV). Often it lies somewhere in the middle. We advocate a repair strategy that creates a fully symmetrical 180-degree valve in all cases except those where the commissural angle truly lies close to 120 degrees with tricuspid-like configuration. For isolated AV repair to be possible, the coronary ostia must lie below the level of the STJ. Trainees are taught how to evaluate gated computed tomography images of the aortic root to decipher the position of the coronary ostia in relation to the STJ. Along with this, they must view and learn to interpret a large volume of echocardiograms, both transthoracic and transesophageal (Video 1). By using the preoperative imaging data, they should prepare a preliminary operative plan for the patient depending on which phenotype of dystrophic AI is present (Figure 1). We teach a standardized series of steps for the operation that are followed in every case:1.Transection of the aorta2.Valve assessment•Inspection•Geometric height measurement•Annulus diameter measurement•Commissural assessment: fenestrations and diastasis3.Sizing of external STJ ring and subvalvular annuloplasty ring4.Dissection down to subvalvular plane including beneath the coronary arteries5.Subvalvular U sutures6.Alignment of cusp free edges7.Sinus plication (if necessary)8.Sinotubular junction ring implantation9.Effective height measurement and cusp resuspension10.Subvalvular ring implantation11.Aortotomy closure Trainees first learn how to assist in these procedures, after which they are helped to perform the steps themselves. In the following steps, we describe the operation for an isolated repair of a right-left fusion BAV using double subvalvular and supravalvular annuloplasty. The same steps can be used for a right-non fusion BAV, with the appropriate adjustments. Later in the Specific Lesion Sets section of this article, we describe the indications and techniques for hemi-remodeling of the root with subvalvular annuloplasty. A complete transverse aortotomy is performed 1 to 2 cm above the STJ after the aorta has been clamped and the pulmonary vein vent placed. Direct antegrade ostial cardioplegia is given into the coronary ostia using Custodiol HTK cardioplegia solution (Essential Pharmaceuticals, Durham, NC) for 7 minutes. The trainee must have assessed the coronary angiogram before surgery, especially looking for a short or absent left main stem (more common in BAV). A full valve assessment is carried out. The first step is to assess the relationship between the coronary ostia and the commissures, to determine whether an isolated AV repair is possible. If the coronary ostia are above the level of the commissures (ie, above the STJ), placement of an external STJ ring will compress the coronaries and is therefore not possible. In this situation, a full valve-sparing root replacement will be necessary, along with coronary reimplantation and subvalvular annuloplasty.5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar The valve will need to be exposed to carry out a thorough assessment. Two 4-0 polypropylene commissural stay sutures are placed, taking thick bites of the aorta at the tip of each commissure. These are placed under tension at exactly 180 degrees to expose the valve in a symmetrical manner. A third stay suture is placed on the aortic wall above the raphe to improve exposure to the valve. Tissue quality, mobility, and degree of calcification of each cusp should be examined, along with how thickened and restrictive the raphe is in the fused cusp. The commissures should be examined to look for a minor form of unicuspid valve, where only one true commissure exists, with the other two raphes being of a lower height. If the commissures are splayed apart (diastasis), that may need to be addressed. The trainee must handle the cusps gently and look for fenestrations. If small and physiologic, these should be left alone. If elongated or ruptured, and involved in the mechanism of AI, they will require repair. Measuring the geometric height of the non-fused cusp will indicate whether it is retracted (a potential risk factor for repair failure). A cutoff of less than 19 mm geometric height implies retraction. The nodule of Arantius must be grasped with forceps and the cusp stretched while the two adjacent commissures are pulled away from each other. A ruler measures the distance from the nadir of the non-fused cusp to its free edge, which is the geometric height (Video 2). One of the important aims of the repair procedure is to restore the STJ/annulus ratio back to its physiologic figure of 1.2. The trainee learns that an external ring at the level of the STJ will result in an STJ diameter similar to the ring size, given the negligible thickness of the aortic wall. At the annulus, however, the wall is muscular, with an average thickness of 2.5 mm. Therefore, an external subvalvular ring will produce an annulus 5 mm smaller than the ring size. A Hegar dilator is used to measure the annulus size by intubating the aortic root. The correct size of the annulus is chosen by which dilator fits snuggly and passes through the annulus. Care must be taken to avoid damage to the cusps. Using the measured size of the annulus, the size of both the closed (for STJ) and open (for annulus) expansile external annuloplasty rings (Extra-Aortic; Coroneo, Montreal, QC, Canada) are chosen according to the algorithm (see Table 1).Table 1Sizing for Calibrated Subvalvular Aortic Ring and Supravalvular Sinotubular Junction Annuloplasty Extra-Aortic Ring Based on Aortic Annulus Size MeasurementAdapted from Youssefi and colleagues6Youssefi P. Zacek P. Debauchez M. Lansac E. Isolated tricuspid aortic valve repair with double annuloplasty: how I teach it.Ann Thorac Surg. 2019; 108: 987-994Abstract Full Text Full Text PDF Scopus (6) Google Scholar with permission from The Society of Thoracic Surgeons.SizingAortic Annulus Diameter, mmaHegar dilator.25-2728-3031-35≥36Subvalvular aortic ring, mm25272931STJ Extra-Aortic ring, mm25272931STJ, sinotubular junction.a Hegar dilator. Open table in a new tab STJ, sinotubular junction. One of the more challenging steps of the operation is dissection down to the subvalvular plane. This deep dissection allows for the subvalvular annuloplasty ring to be placed in its correct position, thereby reducing the annulus and increasing coaptation height of the cusps. In isolated AV repair, the coronary buttons are not disconnected from the root; therefore, the dissection will also have to performed underneath the coronary arteries. We perform this dissection using cautery, at the same setting as used for internal mammary harvest; however, it can also be carried out safely using scissors. The dissection must be carried out deeply until the trainee reaches a plane corresponding to below the level of the nadir of the two cusps. The trainee starts at the non-coronary sinus. The dissection plane here is between the roof of the left atrium and the aortic wall. Near the right-non commissure, the dissection is better carried out with scissors, to avoid burn injury to the Bundle of His. Next, trainees turn their attention to the left hemi-sinus. Initially they must stay away from the left coronary artery, and start their dissection near the raphe. They must dissect between the left hemi-sinus and the pulmonary artery (PA). The plane of dissection should be carried out in a tangential manner, so as to avoid damaging the aorta and inadvertently entering the sinus or left ventricular outflow tract. The aortopulmonary ligament, which is of varying thickness in different patients, will be seen as a fibrous white thickening between the aorta and the PA, and should be divided fully. Once divided, the dissection should be continued deeper until the subvalvular plane is reached. The trainee must now dissect around and underneath the left coronary artery. The rule for this dissection is the importance of fully visualizing the coronary. Therefore, the fascial roof that overlies the proximal left coronary artery (corresponding to the upper limit of the transverse sinus) must be divided for the coronary to be fully visualized. The trainee should pull the aorta and the PA away from each other, which will help expose this fascia extending between the two structures. Cautery is used to divide the fascia, staying close to the PA. The left coronary artery should now be easily visualized and identified. In BAVs, it is important to assess the coronary angiogram for a short left main stem, or even a separate circumflex artery ostium. The plane underneath the left coronary artery can now be safely dissected using a right-angled dissector, keeping the instrument close to the aortic wall so as to not catch the circumflex artery. The dissector should be carefully opened and gently pressed down to open the plane underneath the coronary artery to a deep subvalvular level. The dissection that has been carried out at the left hemi-sinus should now continue toward the right hemi-sinus. At the left-right raphe, trainees must change their angle of dissection from the tangential dissection carried out at the left hemi-sinus, to a more vertical dissection angle for the right hemi-sinus. That means staying very close to the aortic wall and dissecting vertically down, to avoid inadvertently entering the right ventricle/infundibulum. They must constantly look inside the root to assess how close they are to the right coronary artery. Subsequently, the dissection must also be carried out on the other side of the right coronary artery. When dissecting at the right-non commissure, the depth of dissection that can be achieved is limited by the membranous septum. Instead of using cautery to dissect, which will potentially damage the Bundle of His, they must use scissors instead. A right-angled dissector can be used again to go underneath the right coronary artery, opened, and pushed down to widen the tunnel. Finally, the trainee clamps the venous line to check for any bleeding from the right ventricle/infundibulum/pulmonary artery (Video 3). For the external subvalvular annuloplasty ring to be inserted, six or more subvalvular “U” sutures are required. Whereas the U sutures are inserted at this stage of the procedure, the external subvalvular ring is not implanted until the end so that the remaining steps of repairing the valve cusps can be performed on an untouched and often large annulus. They start beneath the non-coronary cusp, with the needle (Ethicon 3/8 25-mm pledgetted needle; Ethicon, Johnson & Johnson, Bridgewater, NJ) entering inside the aorta 2 mm below the cusp’s nadir. The needle must exit the aorta at the lowest point of the dissection plane, so as to help seat the external ring deep down at the subvalvular level. The second U suture is then placed at the base of the interleaflet triangle of the left-non commissure. The third U suture must pass underneath the left coronary artery. Trainees can now see the importance of separating the fascia between the PA and the aorta to unroof the left coronary artery and fully visualize the structure during this maneuver. They must place the suture so that it enters 2 mm below the nadir of the left hemicusp. Then the needle-holder must immediately be turned toward the operating surgeon so that the needle exits the aorta through the tunnel underneath the left coronary artery and comes out without touching the artery. This suture is placed backhand for a right-handed surgeon. The trainee will need to place subsequent U sutures underneath the left-right raphe and the right hemicusp. In very large annuli (ie, >28 mm), an extra suture can be placed on either side of the left-right raphe into the muscular part of the annulus. The final suture is at the right-non commissure, and is an external nonpledgetted suture placed on the left atrium wall at the lowest level of the dissection plane, to avoid damage to the Bundle of His (see Figure 2; Video 4). We aim to create a symmetrical valve when performing BAV repair, with 180-degree configuration (except for rare cases of a minor form of BAV where the commissural configuration is close to 120 degrees). The free edge length of both cusps must be equalized before carrying out an STJ annuloplasty. Commonly, the fused cusp will have an excess free margin length in BAVs compared with the non-fused cusp. To compare the two cusps’ free margin lengths, the trainee places a 5-0 polypropylene stay suture through the central nodule of Arantius of the non-fused cusp. This stay suture and the right-non commissure are pulled away from each other, thereby straightening the free margin. The free margin of the fused cusp is also straightened by either grasping carefully the nodule of Arantius, or by placing another 5-0 polypropylene stay suture through it. The two straightened free margins are lined up adjacent to each other, which shows the excess length in the right hemicusp. Another 5-0 polypropylene needle is inserted into the free margin of the fused cusp exactly in line with the stay suture in the nodule of Arantius of the non-fused cusp. The same must be repeated for the left hemicusp to straighten both free margins. The trainee must then take the same 5-0 polypropylene needle which they had previously placed through the free margin of the fused cusp, and now pass it through the free margin again exactly in line with the stay suture in the nodule of Arantius of the non-fused cusp. This indicates the length of plication required, and the suture is tied. Then a visual assessment is made by pulling the two commissures apart to straighten both free margins and make sure that they line up, indicating symmetrical free margin lengths (see Figure 3; Video 5). In the majority of cases of BAV, the free margin length of the fused cusp is elongated, and plication can lead to a large area of cusp tissue that is folded by plicating the free margin. It is important to close this folded area using interrupted 5-0 polypropylene sutures to avoid billowing of the valve. If the free margin is very thickened or fibrotic, it can be shaved to facilitate plication. Another option is to carry out a triangular resection of the free margin, which can also be used if the raphe is calcified and stiff, or when the length of plication required is very large. In aiming to create a symmetrical valve and root design with 180-degree commissural orientation, symmetry must also be achieved with the size and configuration of the two sinuses. When commissural orientation is less than 170 degrees, the fused sinus will inevitably be larger than the non-fused sinus. To create two equal-sized sinuses, the fused sinus is plicated using two pledgetted mattress sutures (Ethicon 3/8 25-mm pledgetted needle), one above the other. The lowest mattress suture is inserted first. The needle enters the aorta from the outside to the inside, above the cusps’ insertion into the aorta, on one side of the raphe. If the raphe is very low, the needle can next be passed from the inside to the outside of the aorta on the other side of the raphe. The same is carried out with the other end of the mattress suture, taking bites slightly higher up the aortic sinus. The two needles are passed through another pledget to complete the mattress. The second mattress is placed above the first, higher up the aortic sinus toward the STJ. Finally, the mattress sutures are tied, thereby plicating the sinus in a vertical fashion. In cases where the raphe is high and closer to the height of the two commissures, the sutures of the lower mattress may lie across the raphe, thereby impeding cusp motion. To prevent this happening, once the needle has entered the root, it must next be passed underneath the raphe through the aortic wall, to come out on to the other side of the raphe. Then it can be passed from inside to outside as before (see Figure 4; Video 6). In the valve-sparing root procedures described in the first two articles of this series,4Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar,5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar supravalvular annuloplasty at STJ level is carried out by the graft. In isolated AV repair, an expansible external annuloplasty ring (Extra-Aortic; Coroneo, Montreal, QC, Canada) is used for the STJ annuloplasty. The trainee learns that the STJ ring must also be used to change the commissural orientation of the valve to 180 degrees. A total of five supravalvular U sutures are inserted using horizontal pledgetted mattress sutures (Ethicon 3/8 25-mm pledgetted needle). Two are placed above the commissures, one above the raphe, and one above each coronary artery. The supracommissural U sutures are placed with each needle entering inside the aorta 2 mm above the tip of the commissure, with 3 to 4 mm space between the two sutures of the pledget. Each coronary ostia has a U suture placed 2 mm above it, which prevents the external ring from sliding down and compressing the coronary arteries. The appropriately sized ring is selected. The ring has three marker lines spaced 120 degrees apart. In a BAV repair, the trainee must use a pen to mark the ring at 180 degrees to one of the marker lines. These two markers indicate the position of the two supracommissural U sutures, which must be placed through the ring, by inserting the two needles 1 to 2 mm on either side of each marker line. Another mark must be made on the ring exactly halfway between the two commissural markers. That indicates the position of the supra-raphe U suture, which must also be placed through the ring. The other two supracoronary U sutures are placed around the ring. Once the ring has been parachuted down, the two commissural U sutures are tied down, followed by the supra-raphe U suture. Then the assistant grasps the ring at a commissure and the raphe on either side of one of the supracoronary U sutures and pulls them apart. That straightens the ring and the respective segment of the STJ, and allows the supracoronary U suture to be tied in its natural lying position (see Figure 5; Video 7). A dedicated cusp caliper (Fehling Instruments, Karlstein, Germany) is used to measure the effective height of the non-fused cusp.8Schafers 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 This measurement must be carried out after STJ ring implantation as STJ annuloplasty can induce symmetrical prolapse of the cusps (as well as the beneficial effect of increasing coaptation height). Therefore, any induced prolapse by the STJ annuloplasty, as well as any native cusp prolapse (one of the most important mechanisms of AI) can be treated at this stage. Only the effective height of the non-fused cusp is measured—the raphe of the fused cusp (which corresponds to the hypoplastic subcommissural triangle) prevents correct placement of the caliper owing to the absent cusp nadir. A pressurized root is simulated by pulling the two commissures apart; 4-0 polypropylene stay sutures at the tip of each commissure are used for traction. The caliper is set to 9 mm, and while pulling on the commissural stay sutures, the cusp belly is positioned at the nadir or hingepoint of the non-fused cusp (Figure 6). No further plication is necessary if the effective height of the non-fused cusp reaches 9 mm (because the two cusps’ free margin lengths have already been aligned). We want to preserve as much length as possible of the non-fused cusp without plicating it so as to maintain maximum opening of the valve for long-term function. But if the effective height does not reach 9 mm, then the non-fused cusp’s free margin must be plicated until 9 mm effective height is achieved (Video 8). When a plicating suture is placed in the non-fused cusp, the trainee must place an equivalent plicating suture in the fused cusp, so as to maintain equal free margin length of both cusps. We currently use a Dacron (C.R. Bard, Haverhill, PA) tube graft while awaiting the manufacture of the open version of the external annuloplasty ring (Extra-Aortic; Coroneo). According to the sizing algorithm (Table 1), the correctly sized Dacron tube graft is cut to produce a ring 5 mm wide. This ring must then be cut in one place to make an open ring. The ring is passed through the subvalvular U sutures as well as beneath each coronary artery. Care must be taken to ensure it does not twist on itself. The ring is closed by using the two U suture needles from the middle of the non-coronary sinus, as well as with a separate suture to take bites at each open end and tie (Figure 7). The trainee should start tying at the left-right raphe, with the last sutures to be tied at the noncoronary sinus. That is because the most fragile section of the root at the subvalvular level is at the left-right commissure/raphe, and therefore these sutures should be tied first so that there is very little tension (Video 9). The aortotomy is closed using 4-0 polypropylene, followed by thorough deairing and removal of the cross-clamp. As soon as the cross-clamp is released, transesophageal echocardiography can be used to assess the repair, even with the patient still on cardiopulmonary bypass. Assessment should be made again once cardiopulmonary bypass has been stopped. We only accept grade I central AI. If there is a residual jet that has any degree of eccentric nature (even if grade I), we would reclamp and re-repair as eccentric AI is associated with long-term repair failure. If this is the case, echocardiography should be used to decipher the mechanism of AI before the cross-clamp is reapplied. The aortotomy is reopened and valve assessment is undertaken. In most cases, re-repair can be carried out, but if this is not possible, then both annuloplasty rings are cut and a new prosthetic valve implanted. A number of different valve lesions may be encountered that require specific management or slight alterations to the above techniques. For management of fenestrations, commissural diastasis, calcification, and the minor form of BAV with close to 120-degree commissural angle, please see the previous three articles in the series.4Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I tea