Stentless cylinder-within-a-cylinder reimplantation: modified inclusion root replacement

We illustrate a procedure for implanting a modified stentless cylinder in a patient with bicuspid aortic valve disease with an aortic aneurysm. The modification is based on a unique technique of continuous suturing that mimics reimplantation or the David operation. This technical variant can be applied to auto- and heterografts. The patient is a 50-year-old man with a bicuspid aortic valve type I showing severe stenosis and valve calcifications, with a modest concomitant aortic annulus and root and aorta enlargement of 29 mm, 45 mm and 52 mm, respectively. The outflow suture line is created with 5-0 continuous Prolene suture to secure the cylinder by reimplanting it from the inside to the outside of the aortic root and all the way back. This line begins at the nadirs and runs on both sides from the inside to the outside of each of the two coronary sinuses and back; it resembles the reimplantation technique used in the David operation. The noncoronary sinus forms a neo-aortic root. The technique offers the proven benefits of stabilization of the neo-aortic root within the native root, which is essential for both stentless autograft implants and bicuspid root pathology.