Valve-sparing aortic root replacement in a bicuspid aortic valve with papillary fibroelastoma

We present our surgical strategy in a patient with a bicuspid aortic valve Type I (R/N), aortic root aneurysm and papillary fibroelastoma on the aortic valve's cusp. He underwent valve-sparing aortic root replacement (David V Procedure); we also removed the papillary fibroelastoma from the fused right- and non-coronary cusp. In this case, we used a 34-mm straight Dacron graft for root replacement and an aortic annulus downsized to 30 mm. We use Hegar dilatators for the intraoperative measurement of the aortic annulus. The subvalvular sutures are pledged U-sutures and our usual technique in bicuspid aortic valve is to take 2 on each commissure and 5 on each side so that we end up with 12. For the reimplantation of the aortic rim, we prefer a semi-circumferential suture with a small needle. We plicate the non-fused left cusp, which is our reference for the later reconstruction of the common right- and non-coronary cusp. The key strategy of our bicuspid valve reconstruction is aiming at a 180° non-fused commissure orientation and cusp plication. The coronary ostia and aortic root are marked intraoperatively with a radiopaque marker to facilitate postoperative diagnostics and any future interventions including later catheter-based valve interventions.