Severe aortic valve insufficiency with a ‘normal’ appearing aortic root: reimplantation (David) procedure

sutures were placed. Valve inspection revealed a trileaflet aortic valve with thickening of the free margins of all three cusps. The cusps were mobile with no obvious fenestrations or calcification. Inspection of the left cusp suggested some degree of prolapse, with bending of the cusp and the presence of a fibrous band. Inspection of the aortic root revealed normal quality tissue, except in the area of the VAJ under the right coronary cusp. The geometric heights of the left, right, and non-coronary cusps measured 18, 21, and 20 mm, respectively. A 6-0 prolene suture was used to retract the ventricular surface of the cusps and the thickened portion of the leaflets was shaved off with a #11 blade to improve cusp mobility. External dissection of the aortic root was performed to enable access to the VAJ at which level the annuloplasty needs be performed. We started with the non-coronary sinus, dissecting down to the level of leaflet insertion. The sinus was resected, leaving behind a 5–7 mm rim of aortic tissue. A similar dissection was performed after harvesting the right coronary button, followed by the left coronary button. The pulmonary artery and right ventricle were detached from the aortic root. A deep dissection (3) was performed by going through the aorto-pulmonary ligament, which is the white fibrous tissue followed by yellowish fat tissue underneath and then into