Signatory Retention Agreement Made Easy

Signatory ami

here is the case of a 41 years old patient with a 72 millimeter a otic root aneurysm a Otakon sufficiency is great three to four the co-optation is asymmetric and the jet is eccentric towards the mitral valve the valve is tricuspid and the aortic annulus is measured at 26 millimeter the technique consists of a remodeling of the Artic root using a scalloped Dacron tube with 3 neo sinuses of al-safa associated with cusps effective hydro suspension and an external survivor angioplasty using an expensive a otic ring nor a small portion of the ascending outer is rejected and section at the level of the signatory Junction external dissection of the aortic root is perform down to the base of the aortic analysts it begins at the non coronary sinus the wall of the aortic sinus is totally removed leaving a fringe of aortic root of approximately 2 millimeter the aortic root is then liberated from the pulmonary artery and infundibulum and from the roof of the left atrium in order to reach the survival plane here the little ligament between the pulmonary and the Horta is section in order to reach the plane of the septum the dissection is completed by freeing the survival plane and the pulmonary infundibulum and the commissure are individualized and exposure to tree replaced the internal annular diameter is measured with a guy died later at twenty nine millimeter therefore a prosthetic ring 27 millimeter and the valsalva Graf 28 millimeter is chosen five thread of tool coated pledgeted suture are placed from inside out as you stitches in the survival plane the first suture is placed in the middle of the non coronary sinus 2 millimeter below the Nadi of the leaflets the second stitch is placed at the base of the entirely flat triangle at the commissure of the non and left coronary sinus the third suture is placed at the Nydia of the left coronary sinus 2 millimeter below the insertion of the leaflets the fourth suture is passed at the base of the entirely flat triangles at the commissure between the left and right sinus and the fifth suture is placed in the middle of the right coronary sinus two millimeter below the Nadia of the cusps no suture are placed at the base of the Intel effete triangles between the left and the non coronary sinus in order to avoid damages of the membranous septum and lesions of the banner of ease polypropylene six sole stay sutures are passed through each module II of iron choose a grasper pull outward on the corresponding commissure while the two stitches at the level of the notary of Orencia are retracted in the opposite direction of lengths of the free edge then data-mine same steps is performed at each EMA CASP distances between the two stitches determine the area of central placating stitches to equalize the length of each EMA CASP like getting stitches use five O or six solider depending on the thickness of the tissue the remodeling technique is performed using a gel with valsalva graft the distal colour of the skirt below is rejected the graft is calop to have three symmetrical neo sinuses using the linear demarkation on the bulging part of the graft the height of the scalloped to suture the commissure are cut up to the transition point between circumferential and axial fold in the graft the corner of the three flaps are rejected in order to fashion three petals the graft is anastomose following the sigmoid shape of the aortic annulus suture starts at the left coronary sinus at the nadya of the sinus towards the commissure the first stitch is not at the base of the sinus in order to facilitate suture tension another running future is begun and noted at the tip of the commissure towards corresponding ami sinus in order to place the commercial properly without Distortion a few stitches are passed above the sicker part of the graft in order to accommodate the commercial and the graft stitches are passed close to the leaflet insertion you stitches are passed from the inside to the outside of the altar in order to minimize the likelihood of puncturing the cusps the right and non conray sinus are then sutured following the same principle starting initially at the nadir of the cusp and then restarting an Emmy running future from the commissure in order to avoid any distortion in the route reconstruction please note the respected entirely flat triangles after remodeling commercial attraction future our place to mimic a pressurized air recruit in order to measure the effective height of its cusps this 400 polypropylene future are passed at each commissure and pulled on the operating field to be under tension a dedicated cusp caliper is used to evaluate any residual or induced cusps elapsed as described by Professor Schafer's at all the caliper is placed such that the longer and rest on the central lowest point of the insertion line the shorter end is pushed to the free margin with the curve accommodating the margin the right coronary cusp is collapsing the free edge is not touching the bar of the caliper central placating stitches are added on the free edge until an effective height of nine millimeter is obtained on each cusp central placating suture are using 500 polypropylene suture final cost-effective heights evaluation of the three cusps is reassess and any residual prolapse is treated by adding extra placating central stitches the ring holder is removed from the packaging using an adjustable handle the five anchoring new stitches are passed through the inner aspect of the prosthetic expensable Liotta crane the black line on the LT ring and the suture window of the ring holder are meant to ensure the correct positioning of each and your plastic suture in the suturing area between the two elastomer ring without puncturing or scratching them with the suture needle the five suture are placed under tension the ring is descended externally around the remodel a aortic root and the three retention suture are then cut in the designated slot in order to free the Artic ring from its holder and the ring holder is removed the you stitches are tight to secure the ring in survival position here is the final reconstruction of the roots with the remodeling and the ring in the survivor position please note the reconstructed sinus and the injured if red triangles the coronary Ostia are then replanted according to the usual technique the thicker part of the gel we've graphed can be cut to suture the coronary Ostia if they are Ascension Aid which is often the case for the right coronary button distel anastomosis is performed using 414 running suture as a standard fashion transesophageal echocardiography is perform after winning from Calliope and marui bypass when min artic pressure is above 70 millimeter of mercury there is no residual regurge you postoperative vanilla base diameter is 21 millimeter with an effective height of 9 millimeter a trans gastric view is also a good view to show any residual regurge thank you very much for your attention