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To simplify allograft implantation, especially in a case like this where the normal aortic root anatomy was disrupted by the infection and when debridement was carried down to the LVOT muscle, the authors of this video set up three points to run three long polypropylene sutures between—the right and left trigones at the base of a triangle and the opposite head of the triangle between the left and right coronary ostia.
In the allograft, a corresponding mark was made for the head of the triangle opposite of the two trigones. A Hegar dilator was used to size the allograft. A sizer was then used to mark the three points on the LVOT ridge. The first running stitch was started at the left trigone and run to the head of the triangle.
When suturing by the muscle portion of the allograft, surgeons go inside to out in order to see exactly where the aortic valve is positioned. The goal was to place the suture two to three millimeters below the aortic valve. The second stitch was run from the head of the triangle to the right trigone and the third stitch was run from the left trigone to the right trigone. A nerve hook was then used to tighten the suture line all the way around and the coronary buttons were reimplanted. Surgeons tested the buttons for hemostasis by running cardioplegia into the aortic root and clamping. The distal end of the anastomosis was then performed with a running 4-0 polypropylene suture.
Surgeons concluded that the running suture technique has the advantage of distributing tension evenly across fragile tissues, which makes the suture line more hemostatic. The running suture technique is also more time efficient.
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2 Comments
Nice video! Really enjoyed watching it.
I could not quite catch it, does running suture of each commissure gets tied to the other running suture at the end?
Do you also always find that the coronary buttons on the homograft correspond to the pt’s? For me it seems more often than not, that I am creating the buttons in a different spot.
Thank you!
Yes, the 3 running sutures are tied together at the three reference points (left trigone, right trigone, and opposite point). The left coronary button on the homograft almost always corresponds okay to the patient coronary button. Occasionally, if the patient’s RCA button was pushed up by an abscess then I put it on a higher position on the homograft