Suture place and Valve inspection
After sizing the valve, we passed three evenly spaced sutures through the lowest point of each valvular cusp and the prosthetic valve to secure the prosthetic valve in the nadir of the annulus.
We always used non-pledgeted braided polyester-coated sutures with 2–0 non-cutting needles to place the three guiding sutures in the mid-commissural nadir region of the annulus. Using pledgets may create channels that result in PVL and could reduce the effective orifice area.
We inserted the suture from the lower end of the annulus and extracted the inserted needle from the Valsalva wall 4 mm above the annulus.
In cases with a gap in the commissure, we placed an additional everted mattress suture using 4–0 polypropylene monofilament sutures (Figure 2B,C). The position of the valve that we placed was 1 mm higher than the usual recommended position to avoid postoperative arrhythmias such as complete atrioventricular block or left bundle branch block. Again, we did not use pledgets.
We inspected carefully before closing the aortomy. The frame must be checked to ensure that it fits correctly into the distal LVOT. We believe that our additional sutures are an effective way to avoid situations in which there is a gap between the tissue under the annulus and the prosthetic valve in the commissure .
The gap in the smaller size-mismatched patient group was corrected entirely with the additional stitch before positioning the prosthetic valve (Figure 2B).