Single Suture Line Research Articles

Penetrating colon trauma - outcomes related to single versus multiple colonic injuries.

There is no conclusive evidence to guide surgical management in the presence of multiple colonic injuries as opposed to a single colonic injury, and whether multiple colonic suture lines are associated with worse outcomes than single suture lines. We reviewed the outcomes of penetrating colonic trauma in relation to whether patients had single versus multiple colonic suture lines (primary repair or anastomosis) following laparotomy. A retrospective study was conducted at a major trauma centre in South Africa from 2012-2020 for all patients over 18years who had sustained penetrating colon injury. 541 cases were included: 409 with single suture line and 54 with multiple suture lines. There were no differences between groups in terms of mechanism of injury (gunshot vs stab; p = 0.328), Injury Severity Score (p = 0.071), or Penetrating Abdominal Trauma Index (p = 0.396). Admission lactate was worse for multiple suture line patients (p = 0.049), but no other blood gas parameters were different, and there was no higher incidence of damage control surgery (p = 0.558) or ICU admission (p = 0.156) for this group. There was a higher rate of diversion in the multiple suture line group (p < 0.001). Univariable logistic regression did not show an increased risk of gastro-intestinal complications, suture line leak rate, or mortality for multiple suture lines compared to single. It appears that there is no appreciable difference in outcome between patients with a single colonic suture line compared to patients with more than one suture line following trauma laparotomy. In light of this, each injury should be treated on its own merit, in the context of the patient's overall physiological condition, without undue fear of leaving the patient with more than one colonic suture line. However, judicious use of diversion remains advisable.

The Buffalo Trunk Technique for Aortic Arch Reconstruction

The frozen elephant trunk technique facilitates repair of aortic arch and proximal descending aortic pathologic processes. Commercially available hybrid grafts may simplify this approach by allowing for a single suture line, potentially streamlining the distal anastomosis and improving operative times. However, these devices are currently not readily available in United States. We developed a surgical technique, the Buffalo Trunk, to simplify the frozen elephant trunk procedure that obviates the need for a hybrid graft and decreases operating times. Our technique uses a soft-branched graft along with a stent graft to create a distal anastomosis that incorporates the aorta, stent graft, and soft graft in a zone 2 arch reconstruction. Patient characteristics, operative times, and perioperative outcomes were analyzed. A total of 37 patients underwent the Buffalo Trunk procedure compared with 29 patients who underwent the traditional frozen elephant trunk. Bypass and circulatory arrest times were 34 and 18 minutes shorter, respectively, in the Buffalo Trunk group. Total blood transfusions were lower in the Buffalo Trunk group. The stroke rate was 5% and 30-day mortality occurred in 2 patients. No difference was noted in end-organ dysfunction, morbidity, and mortality between the two techniques. The benefits of a hybrid approach to the frozen elephant trunk can be attained without the complex industry-available technology as presented by our technique, the Buffalo Trunk. Evolution of this approach has facilitated shorter circulatory arrest time and subsequently overall decreased operative times without compromising outcomes.

Surgical Repair of umbilical hernia in children

Background: Elective repair of an umbilical hernia is one of the most common surgical operations performed by pediatric surgeons, although most of them resolve spontaneously during the first 3 years of life. The exact technique and steps involved in the repair differ widely among pediatric surgeons. Many pediatric surgeons prefer the transverse interrupted suture technique in rectus sheath closure than the purse string or continuous technique as it isolates the tension to each individual stitch, ensures correct suture placement and precise coaptation of edges. It is less likely to devascularize the incision margin. Interrupted sutures also have the advantage that they can be removed individually if infection or haematoma formed, while the purse string suture or the continuous closure has the disadvantage of being a single suture line holding the fascia together and most of wound dehiscence occurs because sutures cut through the fascia. In this study we give a chance to assess the efficacy of the purse string technique. Objective: The aim of our study is to compare between umbilical hernia repair of rectus sheath with closure by interrupted sutures and purse string technique regarding operative time, intra operative complications (bleeding, intestinal injury), and post-operative complications (edema, hematoma formation, seroma formation, cosmetic appearance & recurrence). Materials & Methods: A total of 30 umbilical hernias in children (17 females and 13 males) were operated in Ain Shams University hospital and El Galaa teaching hospital from September 2017 till May 2018. Results: In this prospective study, 30 cases of umbilical hernia in children aging from two years till the age of ten years including 17 female and 13 male with a ratio of 1.3: 1 were randomly selected from the outpatient clinic of Ain Shams University hospital and Al Galaa teaching hospital were divided into two equal groups, group A underwent the repair of the rectal sheath with purse string suture technique while group B underwent the repair with transverse interrupted suture technique. Conclusion: Conclusively, there are no significant differences between both techniques regarding the intra operative complications and post-operative complications in short term follow up; however, transverse interrupted suture technique appears to consume more time than the purse string technique.

Stentless pericardial valve for acute aortic valve endocarditis with annular destruction

Surgery for aortic-valve endocarditis is still challenging, particularly in combination with destruction of the annulus. Freedom Solo (Solo) is a bovine stentless prosthesis for aortic valve replacement. It is implanted supra-annularly into the aortic wall with a single suture line, without requiring an 'intact' annulus. Thirteen patients received a Solo for endocarditis with annular destruction. Our results showed a low reinfection rate and no patient-prosthesis mismatch. Our contribution intends to show the feasibility of implantation also in case of complicated anatomical conditions, such as destruction of the annulus.

Early postoperative hemodynamics and clinical outcomes of patients receiving freedom solo aortic calve replacement; the Asian Experience

Aim: Freedom SOLO (FS) valve (Sorin Group, Saluggia, Italy) is a stentless aortic valve bioprosthesis that use a single running suture line implanted in supra-annular position. Current study aims to assess the early postoperative hemodynamics and clinical outcomes of patients receiving FS aortic valve replacement (AVR). Methodology: 4 patients (2 male; 2 female; mean age 49.25 ± 23.78 years; range: from 25 to 73) who underwent AVR with FS valve in a single center were enrolled in the study. 2 patients underwent AVR for aortic stenosis and 2 patients for aortic regurgitation. Clinical and biological outcomes were recorded. Echocardiographic parameters were compared between preoperative and 5 months postoperative observation. Results: There was no early mortality reported. Late death was reported in one patient which was non valve related. There were 2 patients who developed early postoperative complication but it was not attributed to the valve itself. The mean transvalvular pressure gradient was 26.50 ± 11.90 mmHg preoperatively and 15.25 ± 10.11 mmHg postoperatively. The mean aortic valve area (AVA) for patients having stenosis improved from 0.74 ± 0.23 cm2 preoperatively to 1.50 ± 0.57 cm2 postoperatively. Preoperatively, the mean left ventricular ejection fraction (LVEF) was 65.75 ± 6.29 % and postoperatively 61.25+_11.84 %. The mean cross-clamp time (CCT) for isolated valve replacement was 80.5 ± 21.92 minutes and 147.00 ± 26.87 minutes. The mean lowest postoperative platelet count recorded was 24.50 ± 6.19 (x109/L). The mean platelet count at discharge was 128.75 ±10.11 (x109/L). Conclusion: The result demonstrated good short-term clinical and hemodynamic outcomes in patients underwent FS aortic valve replacement. However, the study also showed the occurrence of severe thrombocytopenia after FS valve implantation.

Use of Axillary Cannulation for Simultaneous Endo-Occlusion and Antegrade Perfusion during Minimally Invasive Surgery

We aimed to develop an antegrade arterial perfusion method that would allow a single suture line on the heart. Using an 8-mm Dacron graft sewn to the right axillary artery, we performed antegrade arterial flow and simultaneous endo-occlusion, as well as the delivery of antegrade cardioplegia. Five patients underwent right axillary antegrade flow, with intention to use axillary endo-occlusion. There were no deaths, axillary artery injuries, or conversions to sternotomy. One patient who had a small (6 mm) axillary artery required femoral arterial balloon placement with axillary arterial flow. When using a 100-mm endoballoon, transesophageal echo alone is suitable for placement of the endoballoon. All patients are alive and doing well at least 1 year after surgery. The right axillary artery is a suitable conduit for simultaneous endo-occlusion, antegrade flow, and antegrade cardioplegia delivery during mitral valve surgery.

Leaflet Replacement for Aortic Stenosis Using the 3f Stentless Aortic Bioprosthesis: Midterm Results

The 3f aortic bioprosthesis is a stentless valve resembling the native aortic valve. It has been postulated that improved hemodynamic performance with this prosthesis may translate into superior durability. We hereby report the midterm results using this valve substitute. Fifty patients with severe aortic stenosis received the 3f aortic bioprosthesis between 2002 and 2004 in our unit. Clinical outcomes, effective orifice area, mean gradients, and ejection fraction were evaluated at discharge, at 6 and 12 months, and yearly thereafter. Mean follow-up was 52 ± 10 months and was complete in 96% of surviving patients. Hemodynamic performance of the 3f valve was satisfactory for substitutes in the range of 25 mm and 27 mm; smaller valve substitutes showed unfavorable hemodynamic performance with mean gradients of 18 ± 7 mm Hg for 21-mm prosthesis, and 14 ± 5 mm Hg for 23-mm prosthesis. Consequently, the regression of left ventricular hypertrophy was incomplete. Late mortality included 10 patients (valve-related in 1, cardiac-related in 3) for a survival of 77% ± 3% at 4 years. Four patients required reoperation owing to endocarditis in 2 and paravalvular leak in other 2. Freedom from reoperation was 93% at 4 years. Six patients experienced 9 neurologic events, accounting for 82% freedom from neurologic events. Its unique design makes the 3f aortic bioprosthesis less complex to implant than conventional stentless valves, as only a single suture line is necessary. The hemodynamic profile and clinical performance of the prosthesis are inconsistent with the established stentless valves, especially with regard to higher incidence of neurologic complications seen during the follow-up.

Improved results of surgically treated aortic valve endocarditis using a stentless valve

Objective: Surgical treatment of active aortic endocarditis is still accompanied by a high mortality rate and a high rate of recurrence. We tested our results with a stentless valve, requiring only a single supra-annular suture line for insertion, in a high risk patient group.

Initial experience with the Freedom Solo® stentless aortic valve in a low volume centre

Objectives. Freedom Solo is a stentless biological aortic valve which is implanted supra-annularly with a single suture line. An increased risk of postoperative thrombocytopenia in the early postoperative period has been reported in recent studies. In our study we evaluated postoperative haemodynamic performance and thrombocyte-levels. Design. Thirty seven patients who underwent valve implantation of the Sorin Freedom Solo stentless valve were included. The haemodynamic performance of the valve was evaluated by transthoracic echocardiography postoperatively at the fourth day (mean) and after a median of 4.2 months. Results. The mean gradient (mmHg) of Freedom Solo was 7.5 at four days and 8.6 at 4.2 months. Postoperatively no patient had more than grade 1 leakage. Seven percent of the patients had a reduction of thrombocytes to less than 20% of the preoperative level. Seventy six percent had a minimum postoperative thrombocyte level less than 100*109/L. The 30 days mortality in our patient material was zero. Conclusions. Implantation of the Freedom Solo valve was uncomplicated in our experience. Favourable transvalvular gradients and no significant leaks were found. In accordance with the literature, we found a high percentage of patients having a postoperative level of thrombocytes less than 100*109/L after implantation of Freedom Solo.

Invited Commentary

The modified Bentall operation remains the standard for aortic root replacement. Surgical options include a pre-manufactured mechanical aortic root composite graft, a native porcine root, or a biological valve implanted in a tubular or Valsalva graft. Suturing a stented biological valve in the tubular graft is rather easy, but a conventional stentless valve is surgically more demanding and rarely performed. In contrast, implantation of the stentless ATS 3F aortic bioprosthesis (ATS Medical, Minneapolis, MN) in a Valsalva graft is facilitated by the design of the valve with a single inflow suture line and three commissural tabs that have to be sutured to the graft wall only.

Rheic Ocean ophiolitic remnants in southern Iberia questioned by SHRIMP U‐Pb zircon ages on the Beja‐Acebuches amphibolites

The Rheic Ocean was a major oceanic domain between Avalonia and Gondwana in Ordovician‐Silurian times. Most of the Paleozoic plate reconstructions assume that the Rheic Ocean suture lies within southern Iberia, coinciding with the contact between the South Portuguese Zone and the Ossa‐Morena Zone. This paper reports four Sensitive High Resolution Ion Micro‐Probe (SHRIMP) U‐Pb zircon ages from mid‐ocean ridge basalt (MORB)‐featured rocks of the Beja‐Acebuches Amphibolite unit, which crops out along the boundary between the Ossa‐Morena and the South Portuguese Zone, and is considered its most conspicuous suture unit. The obtained ages range from 332 ± 3 to 340 ± 4 Ma, corresponding to the crystallization of the mafic protoliths. These Early Carboniferous ages for the Beja‐Acebuches amphibolites imply that this unit can no longer be viewed as an ophiolite belonging to the Rheic Ocean suture, since this oceanic domain was presumably closed in Devonian times. Tectonic reconstructions joining in a single suture line the Beja‐Acebuches Amphibolite unit in southern Iberia to either the Devonian Lizard ophiolite in southern England or the root zone of the Devonian/Ordovician ophiolitic units in northwest Iberia must be therefore reconsidered because of the age difference. We interpret the Beja‐Acebuches Amphibolite unit to represent a narrow and very ephemeral realm of oceanic‐like crust that opened in Early Carboniferous times, after total consumption of the Rheic Ocean. We suggest that a mantle plume underneath southern Iberia in Early Carboniferous times is the most plausible large‐scale geodynamic scenario for the formation of these MORB‐featured rocks.

Implantation of a Modified Freestyle Valve With a Single Inflow Suture Line: Technical Patterns and Advantages

Subcoronary implantation of stentless valves may be a surgical challenge in the small aortic root. In addition, calcifications of coronary ostia may interfere with the procedure. We present a technique to trim a Freestyle stentlesss root (Medtronic Inc, Minneapolis, MN) and facilitate implantation with a single inflow suture line.

Short-term hemodynamic advantages of stentless CryoLife-O'Brien valve over stented bioprostheses for aortic valve replacement

For the CryoLife-O'Brien valve (CryoLife Inc, Kennesaw, GA, USA), implanted with a single suture line, we aimed to analyze the surgical requests and the hemodynamic results compared to stented bioprostheses. Two groups of patients requiring isolated aortic valve replacement from this population were compared retrospectively: 84 patients receiving the stentless CryoLife-O'Brien valve (Group A) and 94 patients receiving stented bioprostheses (Group B). Preoperative characteristics of patients were statistically equivalent for both groups. Statistically significant differences were observed only for operative durations and post-operative transprosthetic gradients: Aorta cross-clamp and cardio-pulmonary bypass durations were statistically longer for Group A than for Group B (45.9+/-5.7 min vs. 41.1+/-6.8 min; P<0.0001; and 64.3+/-11.6 min vs. 59.3+/-11.9 min, respectively; P=0.0053); maximal gradients and mean gradients were 19.9+/-10.9 mmHg vs. 25.6+/-10.4 mmHg (P=0.0008) and 10.8+/-5.3 mmHg vs. 14.8+/-6.4 mmHg (P<0.0001). Few surgical constraints and early post-operative hemodynamic efficiency of the stentless CryoLife-O'Brien valve means that this bioprosthesis can be intented in current practice for the aortic valve replacement in elderly patients.

Single–suture line placement of a pericardial stentless valve

Implantation of bioprostheses in the supra-annular position with the single suture line was first applied by O'Brien to porcine stentless valves. The aim of this study was to evaluate the clinical performance of the Pericarbon Freedom stentless bioprosthesis (Sorin Biomedica Cardio, Saluggia, Italy) implanted in supra-annular position with the single-suture line technique. The single-suture approach for the Pericarbon Freedom stentless bioprosthesis is obtained by trimming away all the extra tissue of the valve inflow side and scalloping the outflow side. Between February 2002 and August 2004, a total of 65 consecutive patients at our institution (48% male, mean age 69 +/- 12 years) underwent aortic valve replacement with Pericarbon Freedom stentless bioprostheses implanted with a single suture line. Most recurrent etiology was senile degeneration (80%). Pericarbon Freedom 25-mm and 27-mm valves were the most frequently implanted. Thirty patients had concomitant procedures (mainly coronary artery bypass grafting, 16 patients). Overall crossclamp time was 76 +/- 21 minutes. All patients survived intervention. One patient died early of multiorgan failure (postoperative day 16). There were 4 early non-valve-related complications and no late complications at a mean follow-up of 491 +/- 270 days. Four patients showed trivial central prosthetic regurgitation at intraoperative transesophageal echocardiography; among these cases, only 1 was confirmed at 6-month transthoracic echocardiography. At postoperative echocardiographic assessment, mean pressure gradient for the 25- through 29-mm size group was 10.2 +/- 7.1 mm Hg, and peak pressure gradient was 18.1 +/- 12.3 mm Hg. Our initial experience combined a well-established supra-annular implantation technique with the Pericarbon Freedom stentless bioprosthesis, a latest-generation pericardial stentless valve. The combination showed excellent results in terms of safety and reliability, although this technique required adequate experience. Clinical outcomes are similar to those obtained with other techniques, with satisfactory hemodynamic performance.

Valve-Sparing Root Reconstruction

d a h w g U t ver the last decade, valve-sparing aortic root reconstruction has evolved into an important technique in ur surgical armamentarium for dealing with aneurysmal isease of the thoracic aorta. The technique was originally eveloped largely with Marfan syndrome in mind; howver, it is now becoming clear that it has perhaps an even roader application among individuals with degenerative isease, bicuspid aortic valve disease with root dilation, nd even acute aortic dissection. The early and mid-term esults appear promising, although the true late durability ill only be known in the fullness of time. In broad terms, two approaches to the repair of such oot aneurysms have developed. My own exposure to hese techniques began in the early 1990s with the Yacoub echnique. The details of this technique were provided by rofessor Yacoub in the very first volume of Operative echniques in Thoracic and Cardiovascular Surgery. His own esults have been outstanding. Professor Yacoub’s method f excising the sinuses and replacing them with a scalloped raft using a single suture line above the surgical annulus ermits great flexibility in establishing the heights of the ommissural posts and creates full artificial sinuses of Valalva, which are readily appreciable on postoperative studes. While the functional significance of such sinuses reains to be proven, they may be important for preventing ontact of the fragile native leaflet against the Dacron graft

Reoperation on stentless aortic xenografts

Background. Stentless xenografts have been proposed as substitutes for the diseased aortic valve. Cases of valve failure requiring reoperation have thus far been sporadic. To establish the prevalence and outcome of reoperation on stentless aortic xenograft valves, all patients operated on between October 1992 and October 1996 were reviewed. Methods. One hundred ninety-nine patients, 94 men and 105 women aged 70 ± 7 years, had stentless aortic valve replacement for aortic stenosis (in 139), insufficiency (19), or both (38). Three prostheses were used, including the Biocor PSB (Belo Horizonte, Brazil) (106), Toronto SPV (St. Jude Medical, Inc., St. Paul, MN) (52), and O’Brien-Angell (Cryolife, Atlanta, GA) (41). While the Biocor PSB and Toronto SPV prostheses are designed to be implanted freehand with inflow and outflow suture lines, the O’Brien-Angell valve requires a single suture line. Results. There were 7 (3.5%) total and 6 (3%) valve-related reoperative procedures during a follow-up extending up to 4 years (mean 26 ± 20 months). All but one valve-related reoperation, due to endocarditis 36 months after implant, were early (less than 12 months after initial operation). Prevalence of valve-related reinterventions was 1%, 0%, and 12%, and freedom from reoperation at 3 years was 98% ± 2%, 100%, and 81% ± 8%, in patients receiving the Biocor PSB, Toronto SPV, and O’Brien-Angell valves, respectively ( p = 0.0039). Cause of reoperation was technical in 3 (O’Brien-Angell), pannus ingrowth in 1 (O’Brien-Angell), valve tear in 1 (O’Brien-Angell), and endocarditis in 1 (Biocor PSB). All patients survived replacement of the xenograft with a stented bioprosthesis (5) or homograft root (1) and were discharged after a mean hospital stay of 6 ± 3 days (range, 4 to 12 days). At follow-up 15 ± 8 months after reintervention (range, 6 to 34 months), all patients are symptom-free with no evidence of recurrent valve obstruction, regurgitation, or infection. Conclusions. Reoperation for stentless xenograft failure is a rare overall event. Implant of the O’Brien-Angell valve may be associated with a higher prevalence of early reintervention because of nonstructural failure. When needed, reoperation on a stentless xenograft is generally a simple procedure and carries a low surgical risk.

Homograft Aortic Valve Replacement: The Subcoronary and Cylindrical Techniques

Aortic valve replacement using the homograft valve has an important place in the cardiac surgical armamentarium. Despite this, the homograft valve is still not widely used, in part due to the perceived difficulty of the procedure compared with aortic valve replacement using prosthetic devices , less convenient availability of the homograft compared with that of prosthetic devices, and concerns regarding homograft valve failure. This section outlines the subcoronary technique (and its variations) and cylindrical technique for aortic valve replacement using the homograft aortic valve. Homograft aortic valves had a short investigational' and clinical2 application by insertion in the descending thoracic aorta. However, it was Ross3 who first performed a homograft aortic valve replacement in the orthotopic position using a single suture line technique based on the work of Duran and Gunning4 In the same year, working independently, Barrett-Boyes5 also described the subcoronary technique using a double

Rapid intraoperative facial nerve expansion

The repair of nerve length defect presents a reconstructive challenge after trauma and oncologic resection. This study examined rapid intraoperative nerve expansion as a method of repairing nerve length defects with the cat facial nerve model. We compared expanded nerves with grafted nerves and intact nerves 1 year after repair using the criteria of gross function (symmetry and blink reflex according to a modified House scale), electromyography thresholds, nerve-conduction velocity, morphology, and axon count. Three of the five expanded nerves regenerated, and all of the grafted nerves regenerated. Functional results were similar for the regenerated expanded and the grafted facial nerves, and both methods achieved an equivalent level of function. The facial nerves of the regenerated expanded group, grafted group, and intact group had mean electromyography thresholds of 132 mV, 98 mV, and 134 mV, respectively, and mean conduction velocities of 48.3 mg/second, 47.9 m/second, and 44.7 m/second, respectively. Morphologic examination of all five expanded nerves immediately after the expansion process revealed an intact fascicular structure. However, 1 year after excision of the expanded segment and repair, only three of the five nerves regenerated. Axon count at 1 year was as follows: 404 for the regenerated expanded nerves, 449 for the grafted nerves, and 403 for the intact nerves. The potential advantages of rapid intraoperative nerve expansion over nerve grafting for the repair of nerve gap defects include a single suture line and absence of donor site morbidity. This pilot study demonstrates that rapid intraoperative nerve expansion and regeneration is possible and can be used to repair a nerve length deficit. The development of a rapid and reliable method of intraoperative nerve expansion deserves further study. (Otolaryngol Head Neck Surg 1996;114:605-12.)

Rapid Intraoperative Facial Nerve Expansion

The repair of nerve length defect presents a reconstructive challenge after trauma and oncologic resection. This study examined rapid intraoperative nerve expansion as a method of repairing nerve length defects with the cat facial nerve model. We compared expanded nerves with grafted nerves and intact nerves 1 year after repair using the criteria of gross function (symmetry and blink reflex according to a modified House scale), electromyography thresholds, nerve-conduction velocity, morphology, and axon count. Three of the five expanded nerves regenerated, and all of the grafted nerves regenerated. Functional results were similar for the regenerated expanded and the grafted facial nerves, and both methods achieved an equivalent level of function. The facial nerves of the regenerated expanded group, grafted group, and intact group had mean electromyography thresholds of 132 mV, 98 mV, and 134 mV, respectively, and mean conduction velocities of 48.3 mg/second, 47.9 m/second, and 44.7 m/second, respectively. Morphologic examination of all five expanded nerves immediately after the expansion process revealed an intact fascicular structure. However, 1 year after excision of the expanded segment and repair, only three of the five nerves regenerated. Axon count at 1 year was as follows: 404 for the regenerated expanded nerves, 449 for the grafted nerves, and 403 for the intact nerves. The potential advantages of rapid intraoperative nerve expansion over nerve grafting for the repair of nerve gap defects include a single suture line and absence of donor site morbidity. This pilot study demonstrates that rapid intraoperative nerve expansion and regeneration is possible and can be used to repair a nerve length deficit. The development of a rapid and reliable method of intraoperative nerve expansion deserves further study.

The cryolife-O'Brien composite aortic stentless xenograft: surgical technique of implantation

The Cryolife-O'Brien (Cryolife International, Atlanta, GA; formerly the Bravo Cardiovascular Inc valve) stentless porcine aortic xenograft (model 300) is a composite valve of three noncoronary leaflets, symmetric in configuration with a broad coaptive leaflet surface. Because the valve has only a superior aortic wall cuff, a single continuous suture line of 3/0 Prolene provides a rapid, safe implantation. The ideal recipients are elderly patients, who benefit from a short cardiopulmonary bypass period and whose degenerative calcific valves are generally symmetric. The step-by-step technique of implantation is outlined, as are the principles of maintaining symmetry during implantation. The stentless valve has been used for aortic valve replacement in 55 elderly patients, with no deaths and minimal morbidity.